Download Cancer Disease Management

Oncology Outcomes
Introduction to Cancer DM
Gus Manocchia, MD – BCBS of RI
Rick Lee – Quality Oncology
May 13, 2003
Who Gets Cancer?
77% of cancer cases are
diagnosed in people > 55
1,334,100 new cases are
diagnosed each year
Direct Cost of cancer in 2002
was $60.9 Billion
Source: American Cancer Society 2003 Facts & Figures
2
Why Manage Cancer?
3
“When you have a hammer, everything
looks like a nail”
4
Prostate Cancer: 1st Referral = Intervention
Baker
Duval
Clay
Volusia
Citrus
Hernando
240% Variation (FN)
Lake
Seminole
Orange
Pasco
Brevard
Hillsborough
Polk
Pinellas
Tampa Prostatectomy:
Sarasota
1.0/1000 men
St. Petersburg:
3.4/1000 men
Okeechobee
St. Lucie
Highlands
Martin
Charlotte
Glades
Palm Beach
Lee
Broward
Dade
Monroe
Source: Wennberg, J. Dartmouth Atlat of Health Care (1998)
5
Prostatectomy: High Volume Caseload Better
High volume correlates
positively with:
Lower risk of
readmissions
8.2%
8.51
Serious
complications
N = 101,604
Lower risk of
mortality within 30
days
7.81
Low Volume ALOS
High Volume ALOS
Source: Yao, S-L, Lu-Yao G. “Population-Based Study of Relationships Between Hospital Volume of
Prostatectomies, Patient Outcomes, and Length of Hospital Stay.” Journal of National Cancer Institute, 1999,
91:1950-1956
6
Patient Issues Regarding End of Life
80% want to avoid hospitalization and intensive
care at end of life
Chance of being in intensive care is 45% in last 6
mos.
70% wish to die at home; 25% of Americans die at
home
28% of hospice patients die within first week of
admission
Dying in America, Last Acts’ 11 Committees, Nov 2002
7
Coordination of End of Life Care
Theoretical
88.4%
Do
Coordinate
Don't
Coordinate
Actual
43%
Part of My
Routine
Not Part of My
Routine
Poll of 800 Oncologists in the European Society of Medical
Oncologists, surveyed in July 2002 by N Cherny, MD
8
Today’s Unmanaged Cancer
Physicians
Undersupplied
Too many patients/MD: 8 minutes/patient
Reactive
Resent oversight
Treatment variation near end of life
Rely on hospitals for emergencies
Averse to alternative medicine
Don’t welcome discussing death with patients
9
Communication About Death With
Patient
Physician overly optimistic in projecting
likelihood and date of death
40%
37%
23%
Physician levels honestly with patient
Physician refuses patient request to
prognosticate
N. Kristokas, MD et al, Annals of Internal Medicine, June, 2001
10
“Are My Side Effects Life
Threatening?
Fatigue
Anemia
Hair Loss
Nausea and Vomiting
Stomatitis
Infection
Mucositis
Irritable Bowel
Diarrhea
Kidney and Bladder damage
Tissue Damage
Constipation
Acne
Fluid retention
Dry Skin
Peripheral Neuropathy
11
Cancer Patients Receive Inadequate
Analgesia
62%
41%
34%
38%
Lung
Genito-
Gastro-
urinary
intestinal
43%
Breast
Lymphoma
N =522
12
Summer 2000:
Dot Com Bombing
Al vs. George
BCBSRI Decides to Act
13
BCBS of Rhode Island Project
BCBS Membership vs. Other Health Plans
Higher prevalence
More inpatient use
More short stays that could be averted
Much greater ER use
Program Expectations
Move chemo out of hospital
Increase hospice use and LOS
Avert unnecessary ER visits
14
Commercial Cancer Prevalence
Cancer Patients per 1,000 Members
per Year
Commercial Cancer Prevalence Comparison:
85% Higher than Repository
14.0
12.7
12.0
10.0
6.9
8.0
6.0
4.0
2.0
0.0
BLUE CHiP: 1999
LifeMetrix Repository
1999 Blue CHiP data: 625 Malignant Cancer Patients out of 49,082 Commercial HMO members.
15
Hospital Use - Commercial
Commercial Acute Hospital Days/1000 Comparison:
8.0
50.0
6.2
40.0
6.0
4.0
38.3
3.6
30.0
20.0
2.0
20.5
0.0
10.0
Acute Days/1000
Acute Admits/1000
87% Higher Than Repository
0.0
BLUE CHiP: 1999
LifeMetrix Repository
Acute Cancer Days/1000 per Year
Acute Cancer Admits/1000 per Year
1999 Blue CHiP data: 303 Admissions lasting 1,882 days from 49,082 Commercial HMO members.
16
Admission Volume and Costs by
Length of Stay
Distribution of LOS for all Blue CHiP Members
30%
25%
20%
15%
10%
5%
0%
<= 2
3-4
5-7
8-10
11-15
16 to
25
> 25
LOS Ranges (# of Days)
17
ER Visits - Commercial
ER Visits per 1,000 Members per Year
Commercial Emergency Room Visits/1000 Comparison:
3.2 Times Higher than Repository
4.00
3.63
3.00
2.00
0.86
1.00
0.00
BLUE CHiP: 1999
LifeMetrix Repository
1999 Blue CHiP data: 178 ER visits from 49,082 Commercial HMO members.
18
PROVIDER RESPONSE IN R.I.
Reasons many physician groups unwilling to
participate:
“We have our own staff providing this care”
“This is just another layer of bureaucracy between
me and my patient”
“This is too much paperwork for which I receive
no compensation”
“How can a telephonic nurse in Virginia give my
patient the same level of assistance as my in-house
nursing staff or me?”
19
LESSONS LEARNED
Convene Provider Forums… include:
Surgeons,
PCPs,
Medical Oncologists,
Radiation Oncologists
Obtain “buy-in” from high volume groups
Work proactively with the Payer Contracting Dept.
Reimburse for referrals to program
Widely publicize any early successes
20
How QO Performs
Cancer Disease Management
21
What is QO?
Largest cancer care management company in U.S.
17 clients; >5 million lives
Founded in ’93; 3 offices (FL,CA,VA)
Offers a Provider and Patient solution
Licensed Oncology Nurse Care Managers
24/7 access and support
Focus: Manage hospital usage more effectively
URAC accredited
5000 patients under management today
22
QO’s Management Tools
CHA
NHP
T1
T2
T3
T4
48
59
70
53
Humana
65
49
60
41
60
42
53
57
80
70
60
Data Analysis
50
40
30
T1
T2
T3
T4
Telephonic Nurse Care Management
Treatment Authorization Guidelines
Integrated Care Management System
23
Outsourced Telephonic Care
Management
QO role begins at identification of cancer patients
28% of cases are stratified for active case mgmt
Seasoned Oncology RNs in call centers
Proactive Counseling and Side Effect Management
Treatment Plan = Roadmap for proactive CM
24 x 7 access
Peer-to-Peer Medical Director Consultations
24
Communication About Values
With Patient
< 1 Month
Diagnosis
Unmgd
Attack Cancer Aggressively
Pain
Management
Hospice
Referral
Diagnosis
QO
Attack Cancer
Anticancer
Treatment Aggressively
Supportive
Care
Palliative
Care
Psychosocial
Counseling
Pain
Management
Nutrition
Services
Cancer
Rehabilitation
Fatigue
Management
Advanced
Care
Planning
Hospice
Referral
Ongoing
Symptom
Management
25
QO’s Historical Experience with
Treatment Plan Reviews
Cancer Cases
60%
1% of Commercial Membership
Ruled out by stratification criteria
25.2%
Plans approved
11%
Data discrepancies
3.6%
Peer to peer Discussions
0.2% Recommend not to authorize
26
Areas of Impact
Savings by Category
Reduction in
Readmits
Coordination
of End of Life
Averted
ER Visits
Chemo/Rad
Cost Savings
Management of
Complication Rates
27
QO’s Primary Impact on Hospital
Days
3.50
Acute Hospital Days per Cancer Case
3.00
2.50
2.00
3.51
1.50
2.79
3.04
3.00
Medicare Risk:
PY1
Medicare Risk:
PY2
2.68
2.48
1.00
0.50
0.00
Commercial:
Baseline
Commercial: PY1 Commercial: PY2
Medicare Risk:
Baseline
Line of Business / Period
Better Hospice Usage-ALOS
Average Length of Stay in Hospice (Days)
50
45
40
35
30
25
39
34
44
32
36
35
20
15
10
5
0
Customer A
Customer B
QO Goal = 30 Days
Customer C
Customer D
Customer E
Customer F
Medicare Hospice ALOS for cancer = 18 Days
29
Client A: Feb ‘99 – Jan ‘02
Average Annual Cost per
Cancer Patient
$10,000
$9,000
$8,000
$7,000
$9,329
$8,524
$8,713
PY1
PY2
$8,884
$6,000
$5,000
Baseline
PY3
Adjusted Using Cancer Cost Inflation per Milliman USA
Three Year Net Savings: $16+ million
30
Client C: Sept ‘99 – Aug ‘01
$12,000
$11,000
$10,000
$11,301
$11,107
$9,000
$10,043
$9,111
$8,000
$7,000
Baseline
PY1 Adjusted*
PY2 Adjusted*
*Program Administrative Costs Included and Inflation Adjustment per Milliman USA
Two Year Net Savings: $1.5 million
31
Physician Satisfaction
Question
Average Score
PY1
PY2
PY3
QO's CM Staff is courteous and helpful.
4.12
4.20
4.25
QO's CM Program is easy to work with.
3.79
3.95
3.96
QO's CM Staff answer the phone in a timely manner.
3.75
3.89
3.98
QO's CM Staff return phone calls in a timely manner.
3.70
3.77
3.85
Info requested from QO regarding my patient(s) is conducted professionally.
4.22
4.20
4.26
Answers to an urgent referral are obtained from QO promptly.
3.76
4.03
4.06
Obtaining authorizations from QO for my patient(s) is timely.
3.66
4.00
3.94
Our office communicates successfully with QO via fax transmission.
3.91
4.04
4.10
The Orientation provided by QO's PR reps was informative.
3.76
3.81
4.09
QO's PR reps conduct themselves professionally.
4.08
4.27
4.37
Overall, you were satisfied with the interactions you had with QO.
3.85
4.00
4.10
3.86
4.00
4.09
32
Patient Satisfaction Scores
The QO CM** provided me with meaningful information about my cancer and its treatment.
Q1
The info from the QO CM helped me make informed decisions about the care received.
Q2
The QO CM talked to me about the common side effects of my cancer treatment.
Q3
My QO CM talked to me about how to get medical help for side effects if needed.
Q4
2000 Data
(Program Year 2)
I felt my individual needs and preferences were taken into consideration.
Q5
QO helped me with the coordination of care associated with my illness.
Q6
1999 Data
(Program Year 1)
I had good advice from the QO CM on where to find help in the community.
Q7
The QO CM responded to my phone calls in a timely fashion.
Q8
Contact with the QO CM helped me to better understand my health care benefits.
Q9
QO is a valuable part of my health care benefit.
Q10
Overall, I was satisfied with the Cancer Care Program.
Q11
1
Strongly Disagree
2
Disagree
3
Neutral
Average Score per Question
4
5
Agree
Strongly Agree
Results are from an actual QO client in an established market.
Over 500 surveys were mailed over the two years, generating a 37% response rate (versus a targeted response rate of 30%).
CM = Care Manager or Care Management
33
What Do Patients Say About QO?
34