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Building the Oncology
System of the Future
Keynote Address:
Paul H. Keckley, Ph.D., Managing
Director, Navigant Center for
Healthcare Research & Policy
Analysis
ASCO Envisions the Future of
Oncology
Allen S. Lichter, M.D., FASCO
Chief Executive Officer,
American Society of Clinical
Oncology®
What Did We Conclude?
• We are in the throws of three simultaneous
revolutions in medicine and oncology that will play
out over the next 10-15 years.
• Confronting any of these by themselves would be a
daunting task.
• We must manage all three of them simultaneously.
The Three Revolutions
Cancer
Panomics
Big data
Payment
reform/Value
There is Likely a Fourth
Cancer
Panomics
Big data
Payment
reform/Value
Patient
engagement
For today
• In the interest of time, I will skip cancer panomics
• It is a rich topic and we have many ideas in this
domain
• Look at our report at asco.org to see them
From Cost to Value
• Value as the driver of oncology practice - New
payment models that promote quality and value will
prevail:
o Routine quality measurement and improvement
become embedded firmly in practice.
o Providers compensated according to ability to
demonstrate value and quality.
o Public reporting of oncologist performance
becomes routine.
The Value Equation: Keeping
Treatments Affordable
Improving the Value Equation
• ASCO is convening the appropriate stakeholders to begin to
discuss how we could define and quantify “value”
a. We have already published a paper outlining what we believe
are “meaningful outcomes” for new drugs to achieve.
b. We now seek to group existing therapies into value groupings
to assist physician-patient communication.
c. This could have a profound effect on shaping the conversation,
but it will not be easy to do. Stay tuned.
“Big Data” in Oncology
• In the future, most new knowledge creation in
oncology will come from the analysis of “real world
data”
• We will need to create a true “learning health
system” for cancer care.
• ASCO has stepped up to this challenge
Origins of ASCO’s Interest
Embedding Research into Practice
• We’ve lived in a world where research was in one side of the
house and clinical care was on the other
• We now have an opportunity to link the two
• Classical research involving classic clinical trials will continue
• But we can also aggregate data from our routine clinical care
and gain valuable insights from massive numbers of patients
A Key Example:
Our Goal:
To create a national system
capable of collecting the EMR
data from every single medical
oncology encounter in the country.
Our Test:
We built a pilot project in breast
cancer and confirmed feasibility.
Big Data
Next Steps
• Working with ASCO Board of Directors and other volunteer
leadership, we have defined a plan to further develop the
project.
• We are in final negotiations with the partner we will use to
develop the platform.
• We continue to garner philanthropic support and further
engage the clinical community; 12 Vanguard Practices
have been recruited.
• We anticipate a product demo to be available at the 2015
19
ASCO Annual Meeting.
#4: Patient Engagement
• The connected patient
• New devices
• Gathering PROs
• Apps
Summary
• The future of oncology is being shaped by at least
three simultaneous revolutions.
• Cancer panomics will reshape how we diagnose,
treat, and follow our patients.
• An emphasis on value- delivering and measuring
it- will replace a pure cost focus.
• Big data holds the promise of rapidly accelerating
the learning cycle while helping us manage the
“omics” and value issues.
Summary (cont’d)
• We need to continuously monitor the changing
environment so we may shape it for the benefit of
our patients.
• ASCO welcomes your participation in the effort.
Working together, we will create the oncology care
delivery system of the future.
Building the Oncology
System of the Future
Lindsay Conway
Practice Manager, Oncology Roundtable
The Advisory Board Company
[email protected]
202-266-5845
The Retail Revolution
Four Years Post-Reform, New Paradigm Finally Becoming Clear
©2013 The Advisory Board Company • 26851A
Major Themes Reshaping Provider Strategy
1
Medicare Reforms and
the Transition to Risk
2
Coverage Expansion and the Rise
of Individual Insurance
3
Activist Employers and
the Primacy of Value
Source: Health Care Advisory Board interviews and analysis.
A Burgeoning Retail Market
Disrupting Traditional Channels of Coverage
Projected Size of the Potential Retail Market
©2013 The Advisory Board Company • 26851A
2018
1) Based on number of lives falling into the “Medicaid expansion
gap” in non-expansion states.
2) Based on the number of Medicare Advantage enrollees.
2
1
Source: Congressional Budget Office, “May 2013 Estimate of the Effects of the Affordable Care Act on Health Insurance
Coverage,” available at: www.cbo.gov; Accenture, “Are You Ready? Health Insurance Exchanges Are Looming, “ 2013,
available at: www.accenture.com; Kaiser Family Foundation, “The Coverage Gap: Uninsured Poor Adults in States that
Do Not Expand Medicaid,” April 2, 2014, available at: www.kff.org; Health Care Advisory Board interviews and analysis.
How Long Can Employer-Sponsored Coverage
Last?
Cadillac Tax Will Force Pay or Play Decision Starting in 2018
Spectrum of Employer Options for Controlling Health Benefits Expense
Drop Coverage
©2013 The Advisory Board Company • 26851A
Trade Cadillac Tax for
employer mandate penalty
Shift to Private
Exchange
Cap growth of employer
contribution
Convert to
Self-Funding
Hope for success in
controlling total cost growth
Source: Herring B and Lentz LK: “What Can We Expect from the ‘Cadillac Tax’ in 2018 and Beyond?” Inquiry, 2011,
48(4):322-37; Piotrowski J et al., “Health Policy Brief: Excise Tax on ‘Cadillac’ Plans,” Health Affairs, September 12, 2013,
available at: www.healthaffairs.org; Mandelbaum R, “Why Employers Will Stop Offering Health Insurance,” The New York
Times, March 26, 2014, available at: www.boss.blogs.nytimes.com; Health Care Advisory Board interviews and analysis.
Providers No Longer Insulated From Market Forces
Characteristics of a Traditional vs. Retail Market
Traditional Market
Passive employer,
price-insulated employee
Broad, open networks
Retail Market
1
Growing number of buyers
2
Activist employer,
price-sensitive individual
Narrow, custom networks
©2013 The Advisory Board Company • 26851A
Proliferation of product options
No platform for apples-toapples plan comparison
3
Disruptive for employers
to change benefit options
4
Constant employee
premium contribution,
low deductibles
Increased transparency
Reduced switching costs
5
Greater consumer cost exposure
Clear plan comparison
on exchange platforms
Easy for individuals to
switch plans annually
Variable individual
premium contribution,
high deductibles
Source: Health Care Advisory Board interviews and analysis.
Success Requires Winning at Two Points of Sale
©2013 The Advisory Board Company • 26851A
Decision Processes Involved in Provider Choice
Network Assembly
Network Selection
Care Decision
Being chosen by payers, employers,
exchange operators, custom network
builders, and accountable physician entities
to be offered as a network option
Being chosen by
individuals during
enrollment
Being chosen by
patients at the
point of care
1
2
Secure Enrolled Lives
Win Share of Volumes
Source: Health Care Advisory Board interviews and analysis.
Appeal to Network Assemblers
Three Core Attributes
©2013 The Advisory Board Company • 26851A
Cost
Achieve internal
efficiency and implement
population health model
to achieve low total cost
Geographic Reach
and Clinical Scope
Achieve broad geographic
footprint with complete set of
clinical services to meet
employer and individual needs
Clinical and
Service Quality
Achieve superior clinical
quality and invest in
consumer experience to
differentiate from competitors
Source: Health Care Advisory Board interviews and analysis.
Appeal to Patients
©2013 The Advisory Board Company • 26851A
Choosing Three Types of Products
“I have an urgent injury or
illness that must be
addressed immediately”
“I need to have a procedure
done, but it’s not urgent—
where do I go?”
“I want a relationship with a
provider to manage my ongoing
health needs”
Emergent
Care
Shoppable
Procedures
Enhanced
Management
• Low– to-mid acuity
urgent care
• Diagnostic procedures
• Preventative care
• Surgical procedures
• Lifestyle management
• Emergency care
• Therapeutic procedures
• Chronic disease management
Source: Health Care Advisory Board interviews and analysis.
How Cancer Patients “Shop” for Care
Preliminary Data from 2014 Cancer Patient Experience Survey
When deciding where to go for your care, which feature is most and least important?
n=602
Doctor who specializes in my particular cancer
Technology and treatment
options
Clinical quality
In-network for my insurance
Recommendation from my doctor
Accreditation
Patient and support services
Cost
Location
©2013 The Advisory Board Company • 26851A
Availability of appointments
Ranking
Facility and amenities
Customer service
Availability of clinical trials
Recommendation from my family and friends
Source: 2014 Oncology Roundtable Cancer Patient Experience Survey;
Oncology Roundtable analysis.
Creating Cost-Conscious PCPs
CareFirst PCMH Total Cost Incentive Model
Total cost target set
by trending baseline
risk-adjusted PMPM
cost by average
regional cost growth
Risk-adjusted PMPM1 Cost
PMPM Cost
Target
Actual PMPM
Cost
Panel shares in
savings if riskadjusted PMPM
cost is below target
“Virtual panel” of
10-15 PCPs
©2013 The Advisory Board Company • 26851A
Case in Brief: CareFirst BlueCross BlueShield
• Not-for-profit health services company serving 3.4 million members in Maryland, D.C.,
and northern Virginia
• In 2011, launched PCMH program providing opportunities for virtual panels of 10-15
PCPs to earn bonuses based on quality and total cost metrics
• Provides PCPs with color-coded rankings of specialists based on risk-adjusted PMPM
costs
1) Per member per month.
1M
Members covered
by PCMH program
80%
Percent of eligible
PCPs participating
in PCMH program
29%
Average pay
increase for PCPs
receiving bonuses
Source: Overland D, “CareFirst Medical Home Saves More in Second Year,”
FierceHealthPayer, June 7, 2013, available at: www.fiercehealthpayer.com;
Health Care Advisory Board interviews and analysis.
Steering Care to Most Efficient Specialists
Total Cost Transparency Key to Referral Changes
Specialists Color-Coded By Total Cost
27%
Difference in risk-adjusted
PMPM cost between topand bottom-quartile PCPs
66%
Percent of panels earning
bonuses, 2012
PCP Virtual Panels
$98M
©2013 The Advisory Board Company • 26851A
Employed
Specialist A
(Red)
Hospital A
Employed
Specialist B
(Yellow)
Hospital B
Independent
Specialist C
(Green)
Savings from PCMH
program, 2012
“We’re seeing that [the data] changes
the patterns. Now there’s a general
hubbub among the panels to see what
their choices are, and what it costs
them.”
Chet Burrell
President & CEO
CareFirst BlueCross BlueShield
Source: Health Care Advisory Board interviews and analysis.
35
Forging the Path to the Future
Path to Personalized Medicine Converging with Focus on Value
Innovation Drivers
PatientCentered
Care
Clinical Innovation
Personalized
Medicine
Care
Delivery
Innovation
• Prioritization of minimally
invasive approaches
• Genomic medicine
• Comparative effectiveness
research
©2013 The Advisory Board Company • 26851A
Care Delivery Innovation
Targeted
Treatment
•
•
•
•
Payment reform
Consumer demand
Cost pressure
Clinical integration
Clinical Innovation
Source: Oncology Roundtable interviews and analysis.
36
An Era of Experimentation
Numerous Approaches to Realigning Incentives
Payment Models Piloted in Oncology
Complexity and Financial Risk
Fee Schedule
Adjustments
Pathway
Compliance
Bonus
EpisodeBased Pay
Diagnosis/
Treatment
Bundle
Shared
Savings
©2013 The Advisory Board Company • 26851A
+
Adjustments to
payments to
incent greater
use of generics,
or better
payment rates
in return for
quality initiatives
1) Fee-for-service.
Bonus payment
for reaching
pre-determined
pathway
compliance rate
One payment
for select
component of
treatment, can
include case
management;
remainder is
FFS1
Single
payment to
both hospital
and physician
for all services
related to care
delivered
within predefined
episode
Providers at risk
for population;
services billed
FFS1 and
providers share
in savings if cost
kept below predetermined
benchmark
Source: Oncology Roundtable interviews and analysis.
37
Care Delivery Innovation
Enhancing Care Management to Reduce Costs
Success Requires Risk Stratification
Three Distinct Patient Populations and Care Strategies
HighRisk
Patients
©2013 The Advisory Board Company • 26851A
Rising-Risk Patients
Low-Risk Patients
Trade high-cost
services for lowcost management
5% of patients;
usually with complex
disease(s), comorbidities
15%-35% of patients;
may have conditions
not under control
Prevent patients from
becoming high-risk
60%-80% of patients;
any minor conditions
are easily managed
Keep patients
healthy, loyal
to the system
Source: Health Care Advisory Board, Playbook for Population Health Management, Washington,
DC: The Advisory Board Company, 2013; Oncology Roundtable interviews and analysis.
38
Care Delivery Innovation
Different Goals for Different Populations
Three Distinct Population
Strategies
High-Risk
Patients
©2013 The Advisory Board Company • 26851A
Rising-Risk
Patients
Low-Risk
Patients
Representative Cancer Program
Initiatives
•
•
•
•
Multidisciplinary clinics
Intensive patient navigation
Timely hospice enrollment
Caregiver support
Prevent patients from
becoming high-risk
•
•
•
•
Distress screening and management
Systematic phone triage
Timely palliative care referrals
Advanced care planning
Keep patients
healthy, loyal
to the system
•
•
•
•
Cancer screenings
Smoking cessation counseling
Cancer prevention education
Genetic testing
Trade high-cost
services for lowcost management
Source: Oncology Roundtable interviews and analysis.
39
Key Takeaways
1. In order to grow in the future, hospitals need to learn to compete at two points of sale.
They must secure their position in narrow networks, and they must appeal to price-sensitive
patients.
2. Cancer patients tend to be the least cost-sensitive and the least likely patient sub-group to
“shop” for health care services. But as shopping for health care services becomes the norm,
and cancer cost and quality data become more widely available, cancer patients will
become more discerning – and demanding - consumers.
©2013 The Advisory Board Company • 26851A
3. Although cancer patients tend to deprioritize costs when choosing a cancer care provider,
referring physicians are increasingly steering their patients to lower cost specialists,
putting pricing pressure on providers.
4. Multiple payers and providers are working to pilot new oncology payment models that
promote a higher-value cancer care, but the early results are inconclusive. Cancer
providers should expect ongoing experimentation with payment reforms across the
next decade and may want to consider participating in a pilot in order to begin to build the
competencies required to manage risk.
5. To keep costs down, providers must invest in care delivery innovations that proactively
address patients’ medical and psychosocial needs to reduce complications, acute care
episodes, and duplicative or unwanted health care services. One of the cornerstones to
success is risk-stratifying patients and deploying tailored interventions.
Source: Oncology Roundtable interviews and analysis.
Building the Oncology
System of the Future
Gary Lyman, MD, MPH
Co-Director
Fred Hutchison Institute for
Cancer Outcomes Research
Spending on Medicines in Leading Therapy Areas
http://www.imshealth.com/portal/site/imshealth. Accessed May 2014.
Cumulative % Increase
Cancer Care Costs Rising Faster Than Overall Healthcare Costs
Cancer Drugs
Cancer
Medical
Healthcare
US GDP
Note: In 2014, 9 of 12 anticancer therapies approved estimated to cost ≥ $10/000/month.
Eight of Top Ten Most Expensive Drugs Are Cancer Drugs
Top Ten Medicare Drugs 2012
• Ranibizumab
In millions
$ 1,220
• Rituximab cancer treatment
$ 876
• Infliximab injection
$ 704
• Injection pegfilgrastim 6 mg
$ 642
• Bevacizumab injection
$ 624
• Aflibercept 1 mg
$ 384
• Denosumab injection
$ 347
• Oxaliplatin
$ 309
• Pemetrexed injection
$ 292
• Bortezomib injection
$ 278
Includes carrier claims only (physician office and DME).
Outpatient Prospective Payment System (OPPS) claims are excluded.
Source: Moran Company Analysis of Medicare Physician/Supplier Procedure Summary File
Expenditures on Chemotherapy and Targeted
Therapies
Rising Healthcare Costs
•
•
•
•
Cost matters to payers
Cost matters to society
Cost affects access and outcomes
Out of pocket costs matter to patients & affect Rx decisions
Costs
Value in Cancer Care:
Conceptual basis
•
Health Outcome Achieved per $ Spent
•
A multidimensional concept that considers returns for expenditure
“Price is what you pay; Value is what you get.”
- Warren Buffett
Improving Value:
Unique Challenges for Oncology
• Sense of urgency - many cancer patients have poor prognosis & facing
imminent death
• Pressure to use newest technologies/ treatments
• Treatments expensive, making cancer care a hardship or unaffordable
• Treatments can be highly toxic/life-threatening
• Providers often reluctant to switch to best supportive care, even at end
of life
2009 IOM Report: Assessing and Improving the Value in Cancer Care
National Quality and Value Initiatives
Hutchinson Institute for Cancer Outcomes Research
HICOR Research Priorities
• Cancer Care Delivery Research
• Effective Translation of Policy to Clinical Practice
• Supporting Evidence-Based Clinical Practice
• Value in Cancer Care
•
•
•
•
Economic Burden of Cancer for Patients and Society
Cost-effectiveness Alongside Clinical Trials
Value of Information Methods
Early Health Technology Assessment
HICOR’s Value in Cancer Care Consortium
ASCO/ABIM Choosing
Wisely Adherence Metrics
RATE OF UTILIZATION of interventions
that are not recommended /
UNSUPPORTED BY EVIDENCE
Regional Metrics of
Value in Cancer Care
VALUE metrics: MEANINGFUL for
the region, FEASIBLE and efficient
to collect, and ACTIONABLE.
Metrics provide a data-driven foundation for prioritizing
needs/opportunities to improve care
Consortium serves as a network for
cancer care delivery research experiments
Project Implementation and Monitoring
Pre
Post
Pre
Post
 Data collection: baseline, 6 & 12 months
 Tumor registry, billing, clinic & patient reported data
HICOR’s Value in Cancer Care Consortium
ASCO/ABIM Choosing
Wisely Adherence Metrics
RATE OF UTILIZATION of interventions
that are not recommended /
UNSUPPORTED BY EVIDENCE
Regional Metrics of
Value in Cancer Care
VALUE metrics: MEANINGFUL for
the region, FEASIBLE and efficient
to collect, and ACTIONABLE.
Metrics provide a data-driven foundation for prioritizing
needs/opportunities to improve care
Consortium serves as a network for
cancer care delivery research experiments
Participating Organizations
Allied Health Advocates ◊ Centers for Medicare and Medicaid, Region X ◊ Confluence Health ◊
Evergreen Health ◊ Fred Hutchinson Cancer Research Center ◊ Gilda’s Club ◊ Group Health ◊ Island
Hospital ◊ Multicare Regional Cancer Center ◊ Northwest Medical Specialties ◊ Overlake Hospital ◊
Premera Blue Cross ◊ Providence Regional Cancer Partnership ◊ Seattle Cancer Care Alliance Virginia
Mason Medical Center ◊ Swedish Cancer Institute ◊ Washington State Health Care Authority ◊
Washington State Medical Oncology Society
Value in Cancer Care Summit
Allied Health Advocates ◊ Centers for Medicare and Medicaid, Region X ◊ Confluence Health ◊ EvergreenHealth
Fred Hutchinson Cancer Research Center ◊ Gilda’s Club ◊ Island Hospital ◊ Northwest Medical Specialties
Overlake Hospital ◊ Providence Regional Cancer Partnership ◊ Washington State Health Care Authority
Top Six
Desirability
Feasibility