Innovative Cancer Care Initiative #1: Community Oncology Medical Home (COME HOME) Dr. Barbara McAneny Laura Stevens Barr

2. Innovative Cancer Care Initiative #1: Community Oncology Medical Home (COME HOME) Dr. Barbara McAneny Laura Stevens Barry Russo

3. Disclosure Information Barbara McAneny, M.D. Employment or Leadership Position: Innovative Oncology Bus. Sol., CEO, Owner Laura Stevens Employment or Leadership Position: Innovative Oncology Business Solutions, Program Director/CIO Stock Ownership: Innovative Oncology Business Solutions Please note, all disclosures are reported as submitted to the Cancer Center Business Summit and are available at cancerbusinesssummit.com.

4. COME HOME Overview Barbara McAneny MD CEO Laura Stevens Barry Russo www.comehomeprogram.com The project described was supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation. The contents are solely the responsibility of the authors and have not been approved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

5. Health care SpendingMedpac 2013

6. Why Medicare is in Trouble

7. CBO on the P4P demonstration A detailed analysis of the demonstration is currently available only for the first two years. That analysis showed that, for patients in the 10 group practices during the second year, average Medicare spending excluding the bonuses paid to physician groups was about 1 percent below projections; with bonuses included, average Medicare spending was just 0.1 percent below projections—about $7 per beneficiary.

8. MEDPAC March 2011 When patients visit a physician office that is part of a hospital’s outpatient department, Medicare pays a facility fee to the hospital and a reduced fee for the physician’s services. The combined fees paid for visits to hospital-based practices are often more than 50 percent greater than rates paid to freestanding practices.

9. Chemotherapy costs by site of service (annualized) • Physician fee schedule payments: $47,500 • Hospital Outpatient Prospective Payment System: $54,000 • Milliman Client Report Oct 19, 2011 by Fitch and Pyenson

10. Patient’s Inability to pay • 62.1% of Bankruptcies are from Medical bills : 48% of the bills are from Hospitals, 18% drugs, 15% physicians • Annual Health Care Costs $16,771

11. COME HOME Focus on the patients with expensive illnesses What factors can doctors control? What data do we need to prevent complications?

12. CMS/CMMI Grant • $19.8M • 7 practices • Significant savings associated with Oncology Medical Home through reduced ED & IP use • Improve quality of care through triage protocols, team care and clinical pathways • Increase delivery of patient-centered care through after hours clinics, same day appointments, patient education and patient portal

13. COME HOME Practices Northwest Georgia Oncology Centers

14. Data is Crucial • Under current FFS system: data is fragmented • Payers have/keep claims data; generally not shared • Clinical data in EHRs or paper not searchable, useful for population tracking/management • Our Goal: put data in the hand of the users who need it • Integration of clinical and financial data streams • Role-based dashboards to track utilization, cost, and quality of care at patient, provider and clinic level

15. COME HOME Model Oncology Patient 1. Electronic Health Records – to share/track real-time patient information; monitor quality 2. Best Practices Care: Triage, Diagnostic & Therapeutic Pathways 3. Team-Based Care: Med/Rad Onc, Diag Radiology, NPs, RNs, LPNs, Pharmacists, Med Techs, Care Coordinators, first responders – working as team to keep patients in OP setting and out of ER and hospital. Includes active disease management, patient education and on or near-site lab, imaging and pharmacy. 4. Enhanced Access: 24/7 Triage Line with “first responders”. Extended weekday and weekend hours, same day appointments, and automated pathway follow-up reminders for triage nurses 5. Financial Support for Medical Home Services

16. Triage Pathways: Overview • Pathways to manage the symptoms of both cancer and cancer therapy • Nausea, fatigue, rash, headache, etc. • Total of 22 symptoms, plus follow up assessments • First practice went live 5/30/2013 • Last (7th) practice went live 8/22/2013 • Our hypothesis: aggressive symptom management at the practice level will reduce ED visits and hospitalizations • Same day appointments for antibiotics, fluids, acute follow up of reported symptoms

17. Clinical Pathways: Overview • Diagnostic & Therapeutic pathways • EHR-based automated compliance tracking + manual audit of a small % of charts (1-5%) • Status: • Complete: Pancreatic, Breast, Lung and Colon Cancer • In progress: Lymphoma, starts 9/13 and Thyroid, 9/20 • Followed by: Melanoma (approx. deadline Dec 2013)

18. PUTTING TOGETHER THE INFRASTRUCTURE Large amount of staff education prior to roll out of the infrastructure changes Implementation Task Force established Rolled out requests for existing staff to volunteer to help Physician Extenders developed their own schedule to support most of the coverage needs Centralized the phone systems to assist the triage process Implemented the Case Management focused triage process – “don’t we already do that?”

19. Pathway Development Timeline Pancreas Breast Lung Colon Lymphoma Melanoma Thyroid Jan 13 Mar 13 Jul 13 Oct 13 Jan 14 Mar 14 Jan 14 Mar 14 Jul 14 Oct 14 Development Review

20. Pathway Compliance Tracking - Patient Assignment & Quality Measurement • Ensuring that we have the data to effectively place patients on pathways: • ICD9 code/Dx date • Stage • Performance Status • Treatment Intent • Treatment type • Biomarkers where appropriate • Ensuring that we have the data to construct quality measures • E.g. Staging performed within one month of dx (QOPI)

21. Pancreatic Pathway Compliance – Diagnostic Work Up Monitoring • Phase I: Presence of agreed-upon procedures • Phase II: May include “negative” monitoring for off-pathway procedures • Since not all required procedures may be ordered by the medical oncologist, we will may need to search for presence of specific procedure codes in claims

22. Pancreatic Pathway Compliance – Treatment Monitoring • Note: Clinical trials are always compliant • Phase I: Based on regimen name • i.e. “CH PANC NEO 1: Folfirinox” • Naming will be standardized across practices • 1-5% of patients will be audited to ensure that regimen is being given as indicated • Phase II: “Negative” monitoring for off-pathway medications • Phase III: Based on specific agents within each regimen • Including logic for dose adjustments • IV chemo, oral chemo and radiation

23. Calculating Compliance • Compliance = number of events on pathway/total number of events • An event is defined as • An outcome or test result that should be documented in the EHR • Ordering of a test, procedure or medication • If the structured data does not exist to put the patient on a specific pathway, the result of all further events is NA, and the event isn’t counted in the compliance measure, but can be “rescued” by entering the required data.

24. Pathway Compliance – Dashboard Mockup Non-Compliance Events Overall By Cancer Type Your Practice By Cancer Type Non-Compliance Events Overall COME HOME

25. Timeline • July/August • Data Integration • Define Event Models • Sept/October • Work with practices to enter/rename regimens in local EHRs • Initial Training • November • User Acceptance Testing of Compliance Algorithms • December • Go-live for pancreatic & breast cancer pathway • Q1 2014 • Pathways for all 7 cancer types live at all practices

26. Cost savings: Payers’ side of the ledger Direct admissions (no ED) $196,200 Clinic instead of ED visits $1,208,700 Hospice instead of Hospital $3,900,000 Lower ALOS $2,125,000 Avoided Admissions $18,500,040

27. Projected Savings to Medicare (CMS) *Cost Projections based on Medical Expenditure Panel Survey (MEPS) data for Medicare beneficiaries in ‘poor health’, inflated to reflect higher expenditures associated with cancer.

28. OPENING DOORS FOR CONVERSATIONS WITH THE COMMERCIAL PAYERS • One commercial “medical home” deal on the table • Medicare Advantage oncology medical home contract in discussion phase • Medicaid Advantage oncology medical home in discussion phase • Opened new Blue Cross conversations • Created an opportunity for further discussions with the other large commercial payer in our market • Finalizing Oncology medical home relationship with one employer sponsored plan

29. COME HOME Model future • Develop bundled payments/shared savings model • Need to ensure sustainability: medical home costs incurred by practices can be covered by savings that accrue to payers • MASON – Making Accountable Sustainable Oncology Networks • 3 cancers (breast, lung, colorectal) with 7 COME HOME practices • Pts assigned to treatment pool based on clinical characteristics, COME HOME treatment pathways, best practices treatment approaches & patient preferences. Assignment determines: • Clinical pathway and quality measures to be tracked • Prospective, actuarially-determined payment amount based on expected costs, developed risk corridors and co-morbidity of patients • Role-based dashboards to transparently communicate quality and cost information in near real-time • Providers paid FFS + medical home infrastructure fee • Practices incentivized with efficiency and quality withhold pools • Any cost overruns shared equally, excess losses covered through reinsurance