Marybeth Regan Oncology_Management_ by fanzhongqing


									Achieving the Benefits of
  Advanced Oncology

   Marybeth Regan, PhD
Texas Association of Health
     Plans Conference
    October 22, 2008
Dr. Marybeth Regan

   Over 20 years of experience in
    healthcare – Payer, Provider and Life

   Active Speaker, author and educator
    • Oncology Management: Benchmarking for Quality,
      June 08
    • Cancer and Disease Management, Oct 1999
    • Collaboration, The Power of Data Aggregation,
      April, 2008
    • The Eight Dimensions of Care Management, May
           Today’s Presentation

1: Current Trends
2: Opportunities with Analytics
3: Data, Tools and Informatics
4: Administrative, Clinical data and the role of
5: Options
6: Next steps
7: Questions and answers

      Recent Articles include:
• Cancer Patients, Lost in a Maze of Uneven
  Care, 7/29/07, New York Times
• No shortage of Care, 7/29/07, Minneapolis
  Star Tribune
• The Changing Face of Breast Cancer, 10/4/07,
  Time Magazine
• Cancer deaths drop off rapidly, 10/15/07 USA
• New standard calls for ‘whole’ cancer care,
  10/24/07, USA Today
• An Online Window to Cancer Care, Marketing
  Health Services, Summer 2008

                      Oncology Management

      Oncology is a top opportunity
      area for improving care
      and the consumer experience…
             “The decisions [for consumers] can be
          agonizing, in part because the quality of cancer
           care varies among doctors and hospitals.” 1

1   Grady, D, “Cancer Patients, Lost in a Maze of Uneven Care,” New York Times (July 29, 2007)

      Why Improve Oncology Management?
        Rising Costs:
             Nationwide, $78.2 billion in 2006 direct medical costs for cancer1
             Costs are growing at 13% annually—double the overall rate of medical
             Cancer costs contribute 12% to overall commercial medical expenses2
             Four cancer categories represent approximately 50% of total oncology
              spent: breast, lung, prostate, and colorectal
             400+ new drugs in the pipeline for cancer care, over $200 Billion and
              growing [AIS]
             New technologies are expensive
             Lack of documentation supporting variances in treatment, cost and
             77% of cancer is in the age group 55 and older
             Although more survivors, incidence is increasing
             Prevention – smoking, 1/3 due to overweight or obesity, physical inactivity
              and nutrition, 50% detected early through screening
             Lack of transparency which results in confusion and a complicated and
              difficult consumer experience

1   National Institute of Health, ; 2 UHC Internal Data; 3 Atlantic Information Services Publication, Oncology Drug Management, 07; 4 NCCN—abstracts from
    NCCN Outcomes Database
Client ABC Example—500,000 Covered Lives Plan
    Cancer Medical Spending < 65 Population

    Annual Spend

                   150                                   Breast Cancer Spend

                                                         Top 5 Cancer Spend (excl. Breast)

                   100                                   Cancer Spend


                          2006   2007E   2008E   2009E

    • 4,500 cancer patients drive $150m annual spend
    • Growing at 13% or approximately $20m annually
    • Top 4 cancers account for more than 50% of the
    • Breast cancer: expect 1,700 patients equaling                                          7
      $30,000,000 annual spend
   Are members in my network receiving the
    highest quality care?
   Which provider are adhering to clinical treatment
    guidelines and to what degree/
   How is my plan performing compared to other
    plans when it comes to providing quality care?
   How can I identify areas of wide variation and
    prioritize messages to my members and
   What tools should I make available for
   How can I adjust my benefit plan design or
    payment strategy to encourage quality care?

    Opportunities for Improvement—Breast
         Under-treatment with radiation
                “Among women with breast cancer, 15 to 25 percent who
                should have radiation do not receive it” 1
         Under-use of anti-estrogen drug therapy
                “20 to 30 percent [of breast cancer patients] do not take
                the anti-estrogen drugs that are a mainstay” 1
         Inappropriate usage of Herceptin drug therapy
                        “10 percent of the time tumors that are reported to be
                         positive, and thus should respond to Herceptin treatment,
                         are in fact negative” 2
                             • Annual cost of treatment = $40,000

1   Dr. Stephen B. Edge, Roswell Park Cancer Institute, New York Times (July 29, 2007)
2   Dr. Peter Mach, physician at Memorial Sloan-Kettering Cancer Center and member of the National Cancer Policy Forum of the Institute of Medicine,
    Wall Street Journal (October 27, 2007)
                  Granularity Uncovers Potential Cost Savings
       Client ABC Example—500,000 Covered Lives Plan—Herceptin use

                   1800   1,700 patients   $4.2m            1,700 patients                 4.3


                                                                                                 Spend ($m)

                   1000                            saving                                  4
                   800                                                                     3.9

                   400         425                                415
                     0                                                                     3.6
                           Patients    Herceptin Spend      Patients     Herceptin Spend

   Herceptin costs approximately $40,000 annually per patient or $4,240,000
    annually for plan ABC
   Varying levels of data - clinical database would help identify patients who
    should not be on Herceptin
   If 10 patients (2% of Herceptin patients) are identified as inappropriate,
    savings may exceed $400k annually                                                                                     10
Opportunities for Improvement—Prostate
            Over-treatment with radical surgery
                          A study of 24,405 prostate cancer patients found that “10 percent
                           [with cancers of low risk] were over-treated with radical surgery” 1

                       • One surgery averages $12,150                                       4

            Over-treatment with radiation
                          “45 percent [with cancers of low risk were over-treated] with
                           radiation” 2
                      • Average radiation cost $57,357 (6 week TX)                                                   5

            Increased use of experienced surgeons
                          Patients treated by inexperienced surgeons (< 10 prostate
                           surgeries) are 70% more likely to have a recurrence within 5
                           years, as compared to patients treated by experienced surgeons
                           (> 250 prostate surgeries) 3

1, 2   New York Times (July 29, 2007)
3   Vickers, Andrew; et al. “The Surgical Learning Curve for Prostate Cancer Control After Radical Prostatectomy,” JNCI, 2007 99(15):1171-1177
4   Brooke Army Hospital, Dr. Natania Piper,
5   Andre Konski, Medical News Today, 11-2006                                                                                                    11
   Physicians Across US: Cost
Comparison for Breast Cancer Treatment

                                                    For every member that is
 $10,000                                           steered from a 1 star doctor to
                                                   a 4 or 5 star doctor, the health
  $9,000                                           plan saves $6,251 per year.
  $8,000                                            Source: Ingenix





           1 star   2 star   3 star   4 & 5 star

        Opportunities for Improvement—Colon
         Under-treatment with appropriate chemotherapy
                       “ . . . half a dozen studies had found that in stage three,
                        when tumor cells have spread to lymph nodes, only about
                        65 percent of patients are given chemotherapy—even
                        though it has been proved beneficial and is recommended
                        for about 80 percent of patients.” 1
                  • Recurrence of disease: $30,000 2
         Encourage screening of high-risk candidates
                       “Only 39 percent of colon cancers are detected early . . .
                        only about half of those who should be tested actually are.”

                            • Cost of colonoscopy: $500–$1000
                            • Cost of colon cancer early stage: $30,000                                                2

                            • Cost of colon cancer late stage: $120,000                                                2

1   Grady, D., “Cancer Patients, Lost in a Maze of Uneven Care,” Quoting Dr. Jane Weeks, Harvard Medical School, New York Times (July 29. 2007)
2   Grady, D., “Cancer Patients, Lost in a Maze of Uneven Care,” New York Times (July 29, 2007)

                  Patient Goals
   Right time
   Right provider
   Right Care
   Right place
   Right cost
   Patient perceives it
    as “right”

            Program Components

                              Wellness &
                              Prevention                 Consumerism
Care Delivery

                              Targeting &

                        Reach and Engage
                   Care                      Condition
                Management                  Management

                             Care Delivery

                      Benchmarks & Metrics

                       Quality Improvement

                    Provider Relationship Mgmt                         15
                                       Consumerism Trends
      One in five (20%) online Americans said the Internet has greatly
       improved the way they get information about healthcare 1
      7 million said themselves used the Internet to cope with a major
      12% of adults – representing 17 million people – said the Internet
       played a crucial role as helped another person cope with a major
      Oncologists estimate that 30% of their patients use the Internet to
       obtain cancer information2
      Information from a study by the Journal of Clinical Oncology states that
       oncologists estimated that only 1/3 of patients that seek information on
       the Internet actually bring to the information to them for discussion2
      75% of oncologists reported that the Internet increased patients’
       understanding of their disease2

                        Consumer decision support tools
                        are key in supporting these trends
1 Pew    Internet & American Life Project Report, May 2, 2006, “Finding Answers Online in Sickness and Health”
2    Journal of Clinical Oncology, March 2003, “American Oncologists’ Views of Internet Use by Cancer            16
    Patients: A Mail Survey of American Society of Clinical Oncology Members”
                “eHarmony for Doctors”
From 34,000 Oncologists
   to the one who is
     “right for me”




         Evaluate Provider Quality
   While searching for an physician (Medical Oncologist,
    provide the ability to review surgeons and the quality and
    volumes for appropriate treatments, i.e. surgeries: radical

           Evaluate Hospital Quality
   Given the Quality and safety issues in U.S. Hospitals –
    provide more information to review selected hospitals
    quality rankings and radical mastectomy surgical volumes

    Authorizes her Provider to see PHR
   Once a care team is identified, a patient
    can provide the authorization to view a
    PHR on-line

                    Add New Physician Access Here

Estimates Treatment Cost for Radical

Checks Health Savings Account to Validate
           Deductible Status

                                Ability to check
                              the HSA account
                              prior to surgery
                               Ability to check

                              status against
                               See what
                              payments have
                              been made or are
                               Checks to see if

                              any of her
                              potential medical
                              expenses will tax
                              deductible         22
        Uses PHR as Treatment Progresses
   As treatment options, in this case a
    Radical Mastectomy, the PHR is used on a
    regular basis to track

    Finds User Forums & Chat Rooms on Breast
   Continuing to use
    the health plan
    dashboard, a
    patient can access
    user forums & chat
    rooms with
    through treatment

         Program Components

                             Wellness &

Benchmarks &
                             Targeting &

                       Reach and Engage
                  Care                      Condition
               Management                  Management

                            Care Delivery

                     Benchmarks & Metrics

                      Quality Improvement

                   Provider Relationship Mgmt           25
             Business Intelligence and analytics

Competitive Advantage

Optimization                                                        What’s the best that can happen?

Predictive modeling                                                 What will happen next?

Forecasting / extrapolation                                         What if these trends continue?                 Analytics

Statistical analysis                                                 Why is this happening?

Alerts                                                               What actions are needed?

Query/drill down                                                     Where exactly is the problem?
                                                                                                                   Access &
Ad hoc reports                                                        How many, how often, where?                  reporting
Standard Reports                                                      What happened?

                                       Degrees of Intelligence                                                           26

   Source: Competing on Analytics, The New Science of Winning, Thomas H. Davenport and Jeanne G. Harris, Harvard
   Business School Press, 2007. adapted from a graphic produced by SAS.
    Business Intelligence, Analytics and Benchmarks
                Oncology Data Landscape
               Benchmarking: “the process of identifying, understanding, and adapting outstanding practices and processes
                  from organizations anywhere in the world to help improve its performance. 1”

    Administrative data has become a standard
    Clinical data standards are still being standardized
    Administrative data can be used as a proxy for performance
     measures in some cases – use and add rules
    Optimal solution is the combination of administrative and
     clinical data compared to clinical guidelines
    Feedback/reporting/evaluation loop by phasing selected
     Oncology reporting measures (and data)
    Once this is completed, the next natural progression is
     benchmarking against regional and national norms
                Where do you begin?
     1   American Productivity & Quality Center

                    Oncology Summary of Costs
                                   Average Cost Per Episode ---------------------------------------------------------------------------
   Episode Family       No.           Total Cost             Total          Mgmt          Surgery        Facility      Ancillary          Pharmacy


Without Surgery           40,594       $63,894,956            $1,574               $7           $35         $252            $621              $659
With Surgery               4,742         66,700,972         $14,066           $1,897        $4,939        $1,148          $5,282              $801

Without Surgery            8,602      $243,944,118          $26,359             $971          $389        $2,226         $13,119            $11,655
With Surgery               9,397      $443,256,490          $47,170           $2,323        $5,694        $4,683         $25,578             $8,893

                       Case Studies of Cost Savings through Oncology
                        Management – Creating Rules and Processes
          Case                                                                                           Program Result and
                                        Issue                               Action
           Study1                                                                                          Estimated Savings
          Herceptin                    12% of Herceptin                    Program implemented         Reduction of
                                         users had not been                   requiring over-              inappropriate
                                         tested for HER2 status               expressed HER2 status
                                         or had an under-                     test result submission
                                                                                                           Herceptin claims
                                         expressed HER2                       prior to initial             $10MM of annual
                                         status                               Herceptin claim              savings realized

          NCCN Drug                    Drugs not on the                    All oncology related        $10MM of annual
           Compendium                    NCCN Drug                            pharmacy claims to be        savings expected in
           Claims Edits                  Compendium were                      evaluated against            overall oncology drug
                                         being prescribed to                  NCCN Drug                    spend
                                         cancer patients;                     Compendium as
                                         inconsistency in                     reference standard
                                         coverage policies

          Erythropoietin               EPO being prescribed                Program implemented         35% reduction in EPO
           (EPO)                         to patients whose                    whereby hematocrit           spend expected
                                         blood cell levels did                level results to be
                                         not warrant use of the               submitted with each
                                         drug                                 claim for evaluation
                                                                              prior to claim payment

    1   UHC internal data results based on HMO fully-insured membership
          Metrics and Benchmarking
   A clinical data management and analytics process                                                 –
    3 steps

    •   Start with administrative data, add clinical data, compares to clinical guidelines
        to enable health plans to improve the quality and efficiency of oncology care
                            1                 +            2
                    Health Plan                      Health Plan
                   Administrative                     Clinical
                       Data                            Data

                                                          +            3
                                                                   Processed and     Medical
                                                                    compared to    Management
                                                                       NCCN          Reports
                                        Merged                       Guidelines

    Clinical Data allows a more robust view of
                treatment protocols
Category of                                                    Administrative and Clinical
               Administrative Data Only
Care                                                           Data

               • Breast cancer patient had an annual           • Breast cancer patient receiving
                 physician visit and annual mammogram            hormone therapy not recommended by
                                                                 NCCN treatment guidelines
               • Within 90 days of the diagnostic procedure,
                 breast cancer patient:                        • Breast cancer patient receiving
Care Pattern                                                     chemotherapy not recommended by
                1) Received radiation or chemotherapy
                                                                 NCCN treatment guidelines
                treatment, or
                2) Had medical oncology or radiation

               • Breast cancer patient with metastatic         • Patient with invasive breast cancer
                 breast cancer to the bone that has received     who is receiving hormone therapy /
                 bisphosphonate treatment in last 12             chemotherapy / radiation therapy as
                 reported months                                 recommended by NCCN guidelines

               • Breast cancer patient compliant with          • Patient taking Herceptin without
                 prescribed                                      evidence of over-expression of HER2
                 anti-estrogen for chemotherapeutic use          tumor marker
                 (minimum compliance 70%)
Drug Use
               • Patient receiving anti-neoplastic
                 medication listed on the NCCN Drug

                                                 Clinical Data Collection
   Collection Methods
                                                                                              Goal is to create a “comprehensive”
                                                                                               solution to reach the targeted
                                                                                               providers to request clinical data
                                         Fax forms
                                                                                              Options to collect data
    Number of Providers Reached

                                                                                                  Fax or online forms

                                                Online forms               solution
                                                                                                  A Pay-for-Performance Plan

                                                                                                  Through an EMR

                                                                                                  Online provider portal

                                                                                                  An on-line patient portal (like
                                                                                                 NCCN) (see article list)

                                                                                                  Care Coordinator / Disease

                                                     Integration with
                                                                             Integration          Medical Home (see Appendix)
                                                                              with EMR
                                                      provider portal
                                                                                                  Results of biopsy
                                               Low                          High

                                         Integration into Provider’s Current Workflow

                          Clinical Data Collection
Positive incentives facilitate the collection of clinical data

     Incentive Category     Description

                            •   Participating physicians receive reports on their
                                performance relative to other network physicians,
                                including individual and aggregate performance data

                            •   Participating physicians do not need to provide
                                notification for selected procedures such as radiology

                            •   Participating physicians are eligible to participate in a
                                health plan’s elite designation program

                            •   Participating physicians receive set payment on a per
                                element or per member basis for providing clinical data

                            •   Participating providers are obligated through their
     Contractual                contracts with the health plan to share specified clinical

    First step: Cancer Patient Identification
Patients and their managing physicians
will be identified using administrative data

    • A report of cancer patients and their
      providers will be generated using
      administrative data

    • Patients will be identified for breast,
      prostate, lung, and colorectal cancers.

    • Report can be narrowed by cancer site,
      geography, etc. to allow for targeted

               Metrics and Benchmarking
          Measures with Administrative and Clinical
                           Data                                                                     Guidelines Index
                                                                                              CMS Code Pages | TOC
                                                                                             Staging, MS, References
                                      Invasive Breast Cancer                                          - See Appendix)

                                                                   See Systemic Adjuvant Treatment – Hormone
                                    HER-2/neu overexpressedj       Responsive Disease – HER-2/neu Overexpressed
                   ER-positive                                     (BINV-5)
                   PR positive
                   Unknown                                         See Systemic Adjuvant Treatment – Hormone
                                    HER-2/neu non-overexpressedj   Responsive Disease – HER-2/neu Non-overexpressed
    Ductal, NOS                                                   (BINV-6)
    Lobular
    Mixed
    Metaplastic                                                   See Systemic Adjuvant Treatment – Hormone
                                    HER-2/neu overexpressedj       Non-responsive Disease – HER-2/neu Overexpressed
                                                                    See Systemic Adjuvant Treatment – Hormone
                                    HER-2/neu non-overexpressedj    Non-responsive Disease – HER-2 Non-overexpressed

              The National Comprehensive Cancer Network is a not-for-profit that
                 develops the “gold-standard” in cancer treatment guidelines
• Benchmarking data allows you to compare your
  performance against peers’ nationwide

• Benchmarks can illuminate quality of care and cost:
         At the plan level
         At the physician level
         By cancer type
         By region
         By other relevant business dimensions

• Benchmarking data can guide several initiatives, including:
         Building outreach programs to providers
         Incentivizing providers to share clinical data
         Assessing performance against national standards
                 Data Analysis Applied to Oncology Management

           Analysis                     Example                                                Action

             • Overall quality          • Compliance to quality      • Setting strategy for    • Target communication to
               measures                   guidelines significantly     overall oncology          breast cancer
                                          lower in breast cancer       management program        oncologists to promote
             • Overall efficiency
                                          than other cancer sites                                NCCN guidelines

               measures                                              • Prioritization of
                                        • Stage IV colon cancer        opportunities for       • Launch colonoscopy
             • NCCN drug
                                          rates and costs higher       improvement               awareness program for
                                          than expected                                          members: health fair
                                                                                                 promotion, waived
                                        • 8% of oncology drug
                                                                                                 copays, etc.
                                          spend is not on NCCN
                                          drug compendium                                      • Pend Non-NCCN claims
                                                                                                 for manual review

             • Provider level quality   • Provider A follows         • Network tiering         • Designate providers on
               measures                   NCCN guidelines 80%                                    Quality and Efficiency
                                                                     • Prioritization of
                                          of the time, Provider B                                measures
             • Provider level                                          provider outreach
                                          40% of the time
               efficiency measures                                                             • Peer to peer outreach to
                                        • Provider A’s average                                   review physician profile
                                          cost per episode unit is                               report with patient
                                          $X, Provider B’s is $2X                                examples

             • Member level quality     • Member not receiving       • Member outreach and     • Oncology DM care

               measures                   radiation according to       education                 manager discusses
                                          guidelines                                             guidelines with patient
                                                                     • Provider outreach and
                                        • Member is taking non-        education               • Peer to peer outreach to
                                          NCCN Rx                                                discuss specific member
                                                                                                 treatment protocol

   Create a steering committee – to develop a game
   Evaluate data – analyze and compare
   Begin with administrative data – understand the
   Look for data gaps that are actionable – find the
    low-hanging fruit
   Add additional data as available
   Created the business care for gathering clinical data
    - define data collection and engage physicians
   Gain consensus for Next Steps

   Consumer Decision Support Strategy is a Must
    • Change the consumer experience – customer

   Identifying the best Doctors - Experience counts
     • Include tools to support Oncology patients find the best
       physician for their cancer

   Apply analytics to data for patient care

   Use of data
    • Apply Business Intelligence to continually evaluate your
       performance on measures that matter to your
       organization and your members

   Benchmarking
    • After benchmarking against your own internal goals,
       evaluate your market position by comparing your        39

       performance regionally and/or nationally
         Contact Information
   Marybeth Regan, PhD
   312-497-3000

   Staging:
    • Stage 0 early – no involvement of surrounding tissue
    • Stage I cancers are localized to one part of the body.
    • Stage II cancers are locally advanced, as are Stage III cancers.
      Whether a cancer is designated as Stage II or Stage III can depend on
      the specific type of cancer; for example, in Hodgkin's Disease, Stage II
      indicates affected lymph nodes on only one side of the diaphragm,
      whereas Stage III indicates affected lymph nodes above and below the
      diaphragm. The specific criteria for Stages II and III therefore differ
      according to diagnosis.
    • Stage IV cancers have often metastasized, or spread to other organs
      or throughout the body.

   Based on the TNM system (next slide)

                        TNM Staging
   Within the TNM system, a cancer may also be designated as recurrent,
    meaning that it has appeared again after being in remission or after all
    visible tumor has been eliminated. Recurrence can either be local,
    meaning that it appears in the same location as the original, or distant,
    meaning that it appears in a different part of the body.

   TNM Staging is used for solid tumors, and is an acronym for the words
    "Tumor", "Nodes", and "Metastases". Each of these criteria is separately
    listed and paired with a number to indicate the TNM stage. For example, a
    T1N2M0 cancer would be a cancer with a T1 tumor, N2 involvement of the
    lymph nodes, and no metastases (no spreading through the body).
   Tumor (T) refers to the primary tumor and carries a number of 0 to 4.
   N represents regional lymph node involvement and can also be ranked
    from 0 to 4.
   Metastasis is represented by the letter M, and is 0 if no metastasis has
    occurred, or else 1 if metastases are present.
   stage, size of tumor, metastatic status, histology, nodal status, and
    hormone receptor status

      Patient-Centered Oncology Medical Home


   Enhanced Access
    Timely Appointment Scheduling – especially important for cancer patients
    Evening, Weekend and Holiday Hours                                                                          Benefits
    After-Hours Support
                                                                                                              Improved Quality at
   Care and Chronic Condition Management
                                                                                                               Lower Cost
    Specialty Referral Coordination and Tracking with Oncology being the primary driver
    Disease and Case Management Enrollment                                                                   Enhanced Patient
   Team Care                                                                                                   Satisfaction
    Physician-directed team both in and outside of the practice setting – key for outpatient chemotherapy
                                                                                                              Improved Patient
    Management of Care Transitions across the Health Care Continuum
   Performance Measurement, Assessment & Improvement                                                          Care Continuity &
    Practice in accordance with clinical evidence
    Performance Evaluation Based on Medical Best Practices                                                    Improved Care
    Measurement of Clinical Processes and Outcomes                                                            Transitions

   Clinical Information Systems                                                                               Improved Practice
    Care Management               Decision Support               Electronic Prescription Filling            Profitability and
ENABLING TECHNOLOGY & CLINICAL SUPPORT                                                                        Value-based
                                     Care Coordination                             Care
  & Tools
                                     Management & Support                          Access                     Simplified and
   Point of Care (POC)
                                      Medical Home                                 24-Hour                   Coordinated Health
                                       Care Advocate                                 Nurse-Line                Care Experience
   Personal Health Record
                                      Educational Materials                        Group Visits
   ER POC Data & Event
    Notification                                                                    eConsultations
                                      Patient Activation Tools
   Electronic Prescriptions          Practice Redesign Support
   Physician Dashboard                                                                                                        43

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