Cancer Care Delivery Reform:The Payer’s Perspective

Quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutions

Michael Kolodziej, MD, FACPNational Medical Director, Oncology Solutions, Aetna

Aetna Inc.

We put people at the center of everything we do

This presentation outlines how we can help members and providers optimize cancer care

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The rising cost of cancer care is everyone’s problem

Cancer care is the leading edge of medical cost trend

Medical Rx30.8%1.5 B

Aetna’s top cost drivers in cancer care

Radiology 22.4%1.1 B

Inpatient23.3%1.1 B

Specialist physician9.4%

483 M

Annual increase

Cancer drugs 20%Cancer medical 12-18%Health care 9%US GDP 3%

1996 20100%

1000% $55 B

$123 B

Cumulative percentage increase

*2010 CY Claims; Commercial & Medicare; All Funding; Excludes AGB/SH/SRC

www.cancer.gov/newscenter/pressreleases/2011/CostCancer2020 

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Principles of our proposed strategy

• Drive efficient use of evidence-based medicine– platform that provides content and workflows– integrate into the Aetna and provider systems – simplify the administrative processes for providers

• Avoid waste and misuse of medical services – better provider alignment

(e.g., Oncology Patient Centered Medical Home), – better network (narrow, tiered)– better decision support strategies

• Leverage and integrate the many current (and future) medical and pharmacy cancer-care initiatives

– seamless, end to end cancer experience for Aetna members and providers

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Increased adherence to evidence based guidelines lowers cost without negatively impacting treatment efficacyStudy: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting”

Published: Journal of Oncology Practice (ASCO Peer Reviewed Journal), 1/19/2010

No change in overall survival between the study groups

Source: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting”. Journal of Oncology Practice. January 2010. Volume 6. No.1. p 12-18

Significantly lowered cost in the case group vs. The control group

Purpose: Evaluate the cost effectiveness of evidence-based treatment pathways for NSCLC patients

Conclusion: Results of this study suggest that treating patients according to evidence-based guidelines is a cost-effective strategy for delivering care to those with NSCLC.

Overall survival by Pathway status.

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Medical management Pathways and evidence based medicine

Clinical pathways are treatment roadmaps of best care practices

• Developed through research and medical evidence

• Provide physicians a more precise approach to cancer care

• Pathway treatment comparison─ Efficacy─ Toxicity (side effects)─ Cost (utilizing generics)

• Pathway lines of therapy─ Combination of drugs

used and the sequencing of how they are given

─ Appropriateness of when to begin treatment and when to discontinue treatment

─ A new line of therapy is generally used when a pathway did not meet clinical outcomes or the cancer progresses

Medical management model*

Pharmacystrategy

Commun-ications

Plan design

Networkdesign

Customerservice

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Platform: Enable administrative easing of prior authorization/pre-certification for practices on the platform

iNexx Platformeviti app

Physician accesses vendor CDS

EBM treatment

plan is built

Oncology clinical decision support

Vendor payer portal

Automated “CDS-code” is delivered

Email notification in near real-time to Aetna UM

Locate CDS code information

Enter CDS code information

etums/ ATV

EDI

Claims processing

Pended via 278 transaction

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1

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3a 3b

Vendor clearing house

270/271 transaction

Local administrator in claims processing can be established

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What are the PCMH joint principles?• Personal physician

— Each patient has an ongoing relationship with a personal physician— Personal physician leads a team of individuals that takes responsibility

for the ongoing care of patients— Personal physician is responsible for providing for all the patient’s

health care needs or arranging care with other qualified professionals

• Care is coordinated across health care system

• Quality and safety are hallmarks of the medical home

• Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication

• Payment recognizes the added value provided to patients who have a patient-centered medical home

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Expected benefits to health care consumers• Improved health outcomes supported by doctors’ use of clinical decision-

support tools to improve care management, tracking and adherence to evidence-based guidelines

• Reduced hospitalizations and ambulatory care— Includes primary and readmissions— Includes sensitive specialty/facility and other costs

• Improved transition of care

• Shared decision making

• Increased engagement in preventive health and wellness

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Medical managementWhat about Oncology medical homes?

Measurements would be those defined initially by the Community Oncology Alliance group such as:

• Percentage adherence to clinical pathways• Percentage of patients with documented

clinical or pathologic staging prior to treatment

• Percentage of ER visits per patient per year• Percentage of Hospital admissions per

patient per year• Percentage of patient deaths occurring in

an acute setting• Average number of days in hospice prior to

death• Percentage of patients with stage IV that

have end-of-life care discussions

Define the components and measurement criteria for designating a provide practice as an Oncology Medical Home (OMH).

Basic components include: • Enhanced communication/patient

education• Coordination and easy patient

access to care• Case management responsibilities• Improved patient tracking of compliance

to medications and follow up activity• Reporting capabilities• NCQA recognition

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Aetna Inc.Emerging Businesses

We have the capabilities to equip oncologists with the tools to transition to a medical home

Care Management Support

Financial Alignment

Oncology Medical Home Solution

Information Technology

Value based contracting and benefit steerage to drive adoption

Clinical decision support tools to optimize care plan

Automated prior-authorization to reduce administrative burden

IT platform for care transitions and holistic view of patients

Optimal Staffing Model to provide leverage and coordinate care Oncology-tailored patient

applications to support patients

Prov

ider

Too

lsPa

tient

Too

lsH

IT P

latf

orm

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Impact of a cancer management program:an Innovent/Aetna pilot

Study Design• Prospective, non-randomized evaluation of patients enrolled in the Innovent Oncology Program

Location • Patients seen by Texas Oncology physicians

Study period• Innovent Oncology Program 6/1/2010-5/31/2012; Program yr 1: 6/1/2010- 5/31/2011; Program yr 2: 5/1/2011-4/31/2012

Inclusion

• Aetna eligible pts diagnosed with an Innovent diagnosis initiating chemotherapy during program year 1 or year 2• Drug costs• ER and in-patient admissions and costs

Exclusion

• Patient eligible for the program in the last month of each program year

• Patients with a chemotherapy claim in the month prior to the program year

• Patients without a chemotherapy claim within each program year

ASCO Quality, 2012 14

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Non-assessable 4%**

Off-pathway

24%

On-pathway

76%

Pathways Compliance

ASCO Quality, 2012 15

Bundles are likely the end result

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Bach, Health Affairs, 2011

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Aetna Inc.Emerging Businesses

ACO

We can also look to leverage ACS to serve oncology practices seeking shared savings through an ACO model

Oncology MH Solution:

Community Oncology Practice

+ Text Text

Text

Text

Oncology Practice

Hospital

Payor

Primary Care Practice

Aetna contracts with community oncology practices to become medical homes

1 Aetna leverages ACS to facilitate relationships between enabled oncology practices and ACOs

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Enablement of oncology-specific component for ACOsB

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The goal

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•Better quality•Lower cost•More value

The current (sorry) state of affairs

The Oncologist and his/her office is stuck in a 20th Century communication and Data exchange environment

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Focus on the patient

Place the patient at the center of enhanced care delivery facilitated through the platform.As practices invite other providers to join their collaboration network, communication and services around their patient’s care are streamlined and simplified.

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Privately or Publicly-Sponsored Medicity Technology Connects Systems to Transform Data Into Action

Patient Portal

Analytics, Clinical Decision Support, Risk-stratified Populations & Quality Measures

Data Aggregation Community Health Record

Identity ManagementBio Surveillance

RegistriesPatient Consent Framework

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iNexx® gives you the power to connect and create the care delivery system that you want

iNexx®ResultReferralOrder

Creating a more collaborative network of care giversVCTR

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Success will require multiple steps

1. Transformation of the clinical practice.2. Evolution of the hospital into an integrated delivery

system.3. Adoption of a culture that espouses performance

measurement and process improvement.4. Modernization of the IT platform, focused on payer,

provider and patient integration.5. Reformation of the reimbursement platform.6. Partnership.

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