Positioning for Value Oriented Oncology Payments: A Toolkit for …arvinagroup.com/images/SROA_2106_Value.pdf · 2018-12-05 · Adequate care delivery platform (evidenced based, collaboration

September 25, 2016

Positioning for Value Oriented Oncology Payments:A Toolkit for Operations & Management Readiness

Society for Radiation Oncology Administrators33rd Annual Meeting

Positioning for Value Oriented Oncology Payments

Session Presenters:Donna Handley, RN, BSN, MAVice PresidentHartford Healthcare Cancer InstituteHartford, CT

Joseph M. Spallina, FAAMA, FACHEDirectorArvina Group, LLCAnn Arbor, [email protected]

Where to find this presentation:

§ SROA website, or§ Arvina Group, LLC, www.arvinagroup.com:

q “About Us”, thenq “Publications”, thenq Scroll to “Cancer Presentations and Publications”.

Discussion TopicsSeptember 25, 2016

I. Background – Value Oriented Insurance Design.

II. 10 – Points: Requirements for Success.

III. Operational and Management Readiness.

IV. Transitioning to Value.

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q Value Defined:§ Value = Delivery of healthcare services assuming financial

risk based on providers meeting specific performance criteria (quality and cost).

§ Common goals:Ø Transition from fee for service Value.Ø Slow the increase in the total cost of care.Ø Reduce waste in healthcare expenditures.

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q Value Defined:§ Value oriented payment is a reimbursement strategy to

measure, report, pay, and reward excellence in healthcare delivery:Ø Offers incentives to providers meeting certain

performance measures, most notably quality and cost of services.

Ø Indirectly takes into consideration access, efficiency, management of healthcare delivery over the course of an episode and throughout the continuum, and alignment of incentives among providers of care.

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q General assumptions:§ You will continue to have broader cancer program

responsibilities.§ Value oriented insurance products will “include” the

broader continuum of care thereby diminishing (eliminating?) traditional provider organizational boundaries.

§ Your markets represent varying stages of value development.

§ Your organization is developing strategies to address the development of value oriented health insurance products.

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Physician Alignment, Medical Home, Decision Support and Analytics, Finance, Quality, IT, etc.

Enterprise Institutes/Service Lines

Cancer Cardiovascular SurgeryNeuroOrthopeadics Etc.

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Enterprise Value Development

Enterprise Strategic Planning

§ Primary & Urgent Care Strategies.§ Population Health Management.§ Physician Alignment (employed & private practice) Strategies.

§ Insurance Specific Strategies.§ Service Line Specific Strategies.§ Etc.

Institute/Service Line Strategic Planning

§ Costs, Quality, Research, Capabilities, Facilities, Care Protocols, etc.§ Access, Markets, Networks, Marketing, Medical Home/Population Health, Telemedicine, etc.§ Value Platform, Governance & Leadership, Provider Goal and Incentives Alignment, Technology Infrastructure, etc.


q General assumptions (continued):§ Cancer program value oriented competency is not fully

developed in your organization.§ Session objective = getting starting with developing a

value competency in your cancer program:Ø Applies to all cancer program types (community,

teaching, academic).

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q 10 - Points - requirements for success (is your program in order to assure success in a Value environment?):1. Organizational acceptance of Value architecture, placing

importance on Value success in the future (starts today).2. Mature governance and organizational structure:§ Performance-based accountability, responsibility, and

authority (e.g., institute and service line structures).3. Adequate care delivery platform (evidenced based,

collaboration across the [adequate] continuum, disease specific, patient safety confidence, engagement of private physicians, innovation and care redesign, etc.).

4. Adequate infrastructure (competency and experienced based) to support value success.

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q 10 - Points requirements for success:5. Team approach and shared decision-making environment

fostered and rewarded (enterprise and Institute/program).6. Cancer program innovation process, orientation towards

clinical redesign encouraged and rewarded.7. Mature strategy and business development platform and

track record of success, including significant and meaningful physician engagement.

8. Well-developed continuous quality, process, and resource utilization improvement measurement and management system and capabilities.

9. Cost accounting and decision support based analytics and financial simulation modeling.

10.Cancer IT best practice.

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q Key Oncology Reimbursement Trends:§ Medicare:

Ø CMS Oncology Care Model.Ø New drug payment mechanism.Ø Role of Oncology Medical Home?Ø Future Value oriented architecture:

ü Oncology is complicated, a multiplicity of diseases, slower transition to Value than other conditions.

ü Unclear, near term, if focus is beyond drugs.ü Bundled oncology payments (selected diseases?), state

rate setting thru Exchanges, other?§ Commercial Payors:

ØSimilarly, unclear and will most likely follow Medicare.

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Positioning for Value Oriented Oncology Payments13

Source: CMS, 2015.

Achievable?


q Key challenges moving forward:§ The transition to value must be managed within a

healthcare organization as a Distinctive Competency!

§ Success with Value oriented healthcare in general and with oncology specifically, requires clinical care delivery redesign (complementing other enterprise initiatives).

§ “It is an imperative that we balance the morale obligation of medicine with the emerging healthcare reimbursement mechanisms.” (J. Levine, M.D., Professor of Medicine, 2015).

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Positioning for Value Oriented Oncology PaymentsFunctional Outcomes

Survivorship Planning

Surveillance

Maintenance

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Prevention

Dx Planning

Care & Treatments

Follow-up

Post Acute Facility

§ Adequately continuum of care development?§ Collaboration across the continuum?§ Engage independent, private physicians?§ Focus shifts from cost of drugs è cost and quality of care across the

continuum?§ Successfully manage the 25% - 35% of cost and quality of cancer care is

outside the control of the hospital and physician practices?

Amount of Control by Hospitals:

More Less


q Key Considerations:§ It’s about performance and the data:

Ø Cost and quality (Patient First!).Ø M3 (measure, monitor, manage).Ø Requirement: adequately developed continuum of

oncology care.Ø History suggests the financial focus will be on reducing

high cost activities:ü Admissions, surgeries, procedures, etc.ü Chemo management (physician practice and home

based) and managing the increasing cost of agents.ü Continuum management (outside enterprise services

are higher risk).ü Economies of scale, platform efficiencies.

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Assessments & Opportunities

Identification (cost, quality, etc.)

Drill Down(DRG, procedure,

process, etc.)

Knowledge Based Solutions Research,

Selection and, Design

Dissemination & Education

Progress Monitoring, Assessment,Adjustments

§Innovation§Quality improvements§Managing variations§Managing risk



q Toolkit Summary:§ Governance and organizational structure.§ Business and services management.§ Patient experience.§ Quality measurement and management.§ Disease specific approaches.§ Efficiency, resource utilization measurement and

management.§ IT best practice.

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Governance and organizational structure:q Performance oriented structure:§ Institute Model for health systems with multiple cancer programs or

service line structure for single program systemsq Governance focusing on quality, growth, and value.q Organization with clearly defined accountability, responsibility and

authority structure:§ Example: Institute structure in multi-cancer program healthcare

enterprise. An approach that is required to successfully maneuver in an uncertain and challenging value world.

q Leadership team maturity key to successful strategy (long term oncology program viability) execution and accomplishment.

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Institute Key Attribute (service line in single program enterprises):q Patients first!q Operating model, governance and leadership structure

(clearly defined accountability, responsibility and authority).q Experienced leadership team (physician and administrative dyad

leadership).q Strategies drive quality and growth.q Enterprise wide single standard of care.q Substantial branding capability.q Membership participation agreement (ComPACT or Conditions of

Participation).q Multidisciplinary team approach to care delivery.

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Institute (continued)q Promotes resource efficiency, excellence, access and care

coordination (LEAN as part of the operating model).q Dashboards linked to Institute annual performance

expectations.q Clinical Quality and Outcomes annual report.q Meaningful and diversified clinical research portfolio.q Promotes innovation, provider alignment, transparency and

documentable performance.q Dedicated support resources (IT, data, quality, planning,

marketing, business development, human resources, finance, decision support and analytics, legal, LEAN sensei, etc.).

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Institute Model: Cancer

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Institute

Enterprise




Key Program Management Requirements:q Clear organizational goals (e.g. Balanced Scorecard, next slide).q Dashboards.q Data transparency.q Management forums.q Physician engagement/strong bidirectional relationships.q Operations and strategy focus and balance.q Lessons learned from your CJR and other colleagues

nationally.q Burdens surrounding success are significant, expedited

learning curve and education infrastructure required.

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Quality Management:q Goals, processes, and outcomes.q Know your and your competitors’ quality positions: M3

(measure, monitor, and manage).q Metrics and targets.q Review & improve.

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Hartford Healthcare Cancer Institute


Patient Experience:q Patients First!! (Services, access, and continuum management).q Access enables and supports the continuum and

coordination of care.q Management of the continuum (cost and quality position)

and evidence based palliative care approaches.q Active management of the formulary (evidence based data for

new and ultra-expensive drugs, guidelines for use of generics, clear process for approval for non formulary drugs, etc.).

q Access supported by IT connections and communications.

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Disease Specific Multidisciplinary Teams:q Require physician leadership with administrative support.q Role and key functions clearly defined.q Clinical councils (Disease Management Teams) and Cancer

conferences provide strong framework for coordinated care.q Evidence based approaches to achieve a single standard of

care (across the enterprise).q Drive quality and outcomes.q Set clinical research agenda.q Innovation incubator.q Patient safety.q Quality, cost, and balance.

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Efficiency, Resource Utilization:q Achieve savings through the use of LEAN to eliminate waste

and focus on continuous clinical process and performance improvement:§ Focus on drugs (average spend is $2.0 - $3.5M per 1.0 FTE

of Hem/Onc), procedures, surgery (65% of cases have surgery), readmissions, infections.

§ Access to data, quick and agile clinical analytics, solution development and rapid improvement is required.

q Staff roles, mix and productivity measures (skill matrix).q Capacities and utilization of key services.q Establish a relationship to and balance between efficiency

and quality.

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IT Best Practicesq Single platform preferable.q Capability and competency to develop interfaces when

necessary.q Culture of strong partnership and collaboration between

clinical teams and IT.q Embedded IT expertise a critical resource:§ Liaison with IT services.§ Project management for complex.

q Quality parameters and ques built into the medical record.

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q Transitioning to Value – Develop your competency:§ Oncology Value architecture currently unclear :

Ø Imperative to develop a Value management competency not diminished!

§ Build your Cancer Institute/Program Value development team (link to institute governance and leadership) and infrastructure:ØMake a routine discussion, start by completing the

Toolkit assessment.§ Cancer Value team identifies opportunities, is connected

with Disease Management Team discussions, and the discussions contribute to enterprise wide Value positioning:ØEarly experiences provide opportunities for learning.

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q Transitioning to Value - Focus on:§ Know your quality and cost positions, and comparison to

competitors (analytic support)!§ Data (cost & quality).§ Continuum of care, clinical innovation, and care redesign.§ Monitor Value development nationally and regionally.

Transforming cancer care to value is complicated, how will future architecture be configured?

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Cancer Institute/Program

Governance

System Value

Committee

Disease Management

Teams

Cancer Value Team

M M

M

M


q Transitioning to Value – It takes teams!:§ Few physician practices are prepared to take risk today

(recent MACRA and MIPS experience):Ø In risk arrangements, hospitals will be educators and

must have solid partnership foundations with practices.ØContinue to work with, strengthen relationships with

independent, private oncology and surgery practices.q Consider payment premiums (routine payments +/- lower

risk) where warranted and when sustained.

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q Transitioning to Value - Summary:§ Value payments have arrived and will proliferate:

Ø Embrace the change if success is in your future!§ House in order to take on risk and succeed (granted,

architecture still unclear)?§ Do you have the teams (Institute/program leadership,

private physicians, fiscal services, population health/decision support/analytics, etc.), how will Cancer value discussions be approached in your organization, etc.?

§ Initial experiences are learning experiences, make the most of them!

§ Encourage explore, innovate, experiment, learn.

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Documents

Positioning for Value Oriented Oncology Payments: A Toolkit for …arvinagroup.com/images/SROA_2106_Value.pdf · 2018-12-05 · Adequate care delivery platform (evidenced based, collaboration