Value Based Care Shift: Oncology Care Model (OCM) · Value Based Care Shift: Oncology Care Model ... The Shift to Value Based Care 3. ... The value based shift emphasizes quality

The US Oncology Network is supported by McKesson Specialty Health. © 2015 McKesson Specialty Health. All rights reserved.The US Oncology Network is supported by McKesson Specialty Health. © 2015 McKesson Specialty Health. All rights reserved.

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Value Based Care Shift:

Oncology Care Model (OCM)

July 28-29, 2016

The US Oncology Network is supported by McKesson Specialty Health. © 2015 McKesson Specialty Health. All rights reserved.

Disclaimer

This information is not intended as legal advice or a substitute for

the original OCM program documents. OCM Participants should

consult the original OCM Participation Agreement and other

guidance published by CMS. OCM Participants are solely

responsible for understanding and satisfying all requisite

conditions of the OCM program, and McKesson Specialty Health

makes no warranty or representation as to the accuracy of the

information contained herein or that it will satisfy the applicable

OCM program requirements.


The Shift to Value Based Care

3


Why are Alternative Payment Models

Emerging?

Current spend isn’t sustainable

Significant variation in quality, drug use and

patient outcomes

Patients are confused, scared and often

experience fragmented delivery of care


Healthcare Cost Trends

5


QUALITY• Achieve better outcomes

• Improve patient satisfaction

COST• Reduce avoidable medical

spending

• Decrease total cost of care

A Market Shift Towards Redefining Value

VALUE =$

6

© 2016 The US Oncology Network. All rights reserved.


Value Based Reform

Legacy fee for service is a volume driven incentive system

The value based shift emphasizes quality and cost (aka…efficiency)

over volume

Alignment is required among payors and providers of resources and

information around populations

Focused on full continuum of care versus episodes

Aligned with Triple Aim …

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Better Health, Better Care, Reduced Cost


Dr. David Fryefield

Volume Reimbursement

We are incentivized to make certain that patients do not receive less than all of the services/care that is

appropriate. In other words, determine the right thing to do and do all of it.

Value Based Reimbursement

Value based reimbursement turns that

upside down, so the incentive becomes to make certain that patients do not receive more services/care than is appropriate. In this scenario, we determine the

right thing to do, and we don't do more than that.

8


“Our goal is to have 85% of all Medicare fee-for-service payments tied

to quality or value by 2016, and 90% by 2018. Perhaps even more

important, our target is to have 30% of Medicare payments tied to

quality or value through alternative payment models by the end of

2016, and 50% of payments by the end of 2018.”

*Sylvia M. Burwell, US Secretary of HHS. N Engl J Med 2015; 372:897-899, March 5, 2015

“Transforming Medicare from a passive payer to an active purchaser of high

quality, efficient healthcare”- CMS

Fee for Service Pay for Value

Setting Value-based Payment Goals — HHS Efforts

to Improve U.S. Health Care*

Example of Financial Incentive: +5% Medicare PFS incentive if >25% practice’s

reimbursement is tied to an Advanced alternate payment model (APM)

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://en.wikipedia.org/wiki/The_New_England_Journal_of_Medicine&ei=kUg6VbeqJsOlsAWNz4DgCA&bvm=bv.91427555,d.b2w&psig=AFQjCNE0wxC7r67SsIJQEL_cDYpdQh9vQg&ust=1429969418174458


Common Understanding of OCM &

Approach

10


OCM Overview

Goal:

• New CMMI payment initiative to advance “better care; smarter spending; healthier

people”

Who’s eligible to participate:

• All Medicare FFS beneficiaries starting chemo for all cancer types

• Other interested payers may also participate, including MA plans, state Medicaid

The proposed model: Episodes are defined as 6 months of chemotherapy

treatment

• Episode starts with chemo claim or Part D claim (oral). Hormone therapies included

• Subsequent episodes can occur for same patient

• Measure total cost of care and performance vs. defined metrics

Two forms of payment:

• $160 per beneficiary/ month fee

• Shared savings performance-based payment to incentivize practices to lower total cost

of care


OCM Focuses on Total Cost of Care

Total health care expenditures will be calculated

beginning AFTER the first chemotherapy administration

or fill date (for orals) :

• Surgery

• Inpatient

• Medications

• Outpatient

• ER

• Radiology

• Lab/Path

12


OCM Concepts of Change

Eligibility &

Enrollment Clinical Navigation

Access to Care 24/7 Documentation Billing


OCM Practice Requirements

1. Provide 24/7 patient access* to an appropriate clinician who has

real-time access to patient’s medical records

2. Use an ONC-certified EHR and attest to Stage 2 of Meaningful Use

by the end of the third model performance year

3. Utilize data for continuous quality improvement

4. Provide core functions of patient navigation*

5. Document a care plan that contains the 13 components in the

Institute of Medicine Care Management Plan

6. Treatments consistent with nationally recognized clinical

guidelines*

14

* Practice attestation


1. Relevant patient information

2. Diagnosis, specific tissue information, relevant biomarkers, and stage

3. Prognosis

4. Treatment goals

5. Initial plan for treatment and proposed duration

6. Expected response to treatment

7. Treatment benefits and harms, including common and rare toxicities

8. Information on quality of life & patient’s likely treatment experience

9. Who will take responsibility for specific aspects of a patient’s care

10. Advance Directives

11. Estimated total and out-of-pocket costs of treatment

12. A plan for addressing a patient’s psychosocial health needs

13. Survivorship Plan Treatment

Plan

The IOM Care Management Plan: 13 Elements

For Internal Use Only – CONFIDENTIAL & PROPRIETARY


Treatment Plan (IOM Elements 1-9)

For Internal Use Only – CONFIDENTIAL & PROPRIETARY

TREATMENT PLAN INFORMATION DATE: Click here to enter a date.

NAME: Click here to enter text.

DOB: Click here to enter text.

My Diagnosis: Click here to enter text.

My Stage: Click here to enter text.

The goal of my therapy is:

Cure Increase my chance of cure after surgery

To shrink the tumor prior to surgery

Help me live as long as possible with the highest quality of life. I know that a cure is not medically

possible.

My Prognosis: Click here to enter text.

Recommended Treatment Frequency Duration

Click here to enter text. Click here to enter text. Click here to enter text.

Expected response to treatment: Click here to enter text.

Alternatives to recommended treatment: Click here to enter text.

Please see attached chemotherapy handouts for specific side effects and details of your treatment regimen

Follow-up appointments for laboratory tests and with your care team will be determined according to your specific

needs, disease, and treatment plan. Please call the office at XXX-XXX-XXXX with any concerning symptoms

and/or questions. During your treatment, we are the first call for any issues and have urgent care appointments

available if needed. We have staff on call 24 hours a day, 7 days a week.

You will meet with a financial counselor to discuss your insurance coverage and out of pocket costs of therapy. We

also have resources available to assist with many of your other needs. Please ask the staff for details.

Patient signature: ______________________________________________________________________

Staff signature: ______________________________________________________________________

Retain copy for patient chart

CLIENT LOGO


Treatment Plan – Live Poll

Will discussion of treatment intent and providing a

Treatment Plan to patient be a significant challenge for

your providers?

• Yes

• No

• Unsure

17

50%

10%

40%

0%

10%

20%

30%

40%

50%

60%

Yes No Unsure

n = 23, from 3/18/16 ED & Lead Session


Why are Treatment Plan Conversations Vital?

IOM Survey of 1068 Adults

18


12 Network practices

~800 physicians

30,000+ Medicare patients/yr.

Onmark: 30+ practices to

participate

Integrated One McKesson

Technology:

- iKnowMed

- Clear Value Plus

- Practice Insights

- RelayHealth

Adoption of Value Base Care:

- Patient Navigation*

- Access to Care 24/7*

- IOM Care Plan*

- Advance Care Planning

- Pathways*

- Self & Claims Based Measures*

- Eligibility & Enrollment

* Adoption required by Oct. 1st

Agreements accepted June 16th

July 1, 2016 OCM start

5 yr. OCM pilot

Financial Benefits:

+$160 MEOS/mo. for 6 mo.

+Share saving vs. utilization

+5% MIPS, if two-sided risk $

Oncology Care Model (OCM)


Phase I:

Awareness

Phase II:

Decision

Phase III:

Mobilization

Mobilization Framework Phases

20

OCM Practice

Selection

OCM

Acceptance


Phase I:

Awareness

Phase II:

Decision

Phase III:

Mobilization

Mobilization Framework Phases

21

OCM Practice

Selection

OCM

Acceptance


Physicians

• Physician team collaboration

• Patient consultation

• Treatment decision

• Treatment plan

• Care path compliance

• 24/7 patient mgmt

• Hi/low risk designation

Medical Assistant

• Patient write-ups & surveillance

• Patient check-in

• ED/Hospital f/u

• Documentation completeness

APP

• F/U patients

• 1 on 1 patient education

• “Urgent care” provider

• ACP planning

• Survivorship

Navigator

• Appointment coordinator

• Care team facilitation


• Monitor hospitalized patients

• Link to outside service providers*

PBR

• Preauths

• Patient financial plan

• Patient assistance f/u

• Patient balance f/u

New patient Intake

• Insurance verification

• Prior medical records

• Schedule appointment

• New patient packet

• ID OCM candidates

Triage

• Proactive patient site of service

mgmt

• Symptom management

• “Call log” follow-up

Social Worker

• Smoking cessation

• Patient needs monitoring

• Psychosocial distress screening

• ESAS follow-up

• Nutrition eval

• My Choices, My Wishes execution

Nurse

• Order safety check

• Group patient education

• TX readiness assessment

• Chair side order/patient check

• Treatment delivery

• Hi/low risk on-going assessment

• Patient surveillance protocols


The “Internal” OCM Patient Care TeamClear roles, responsibilities, and accountability to perform respective roles

* Without team coordination, it falls on the patient to play the coordinating role


The Care Team Huddle

Objective: to improve situational awareness, enhance intra-team communications and

shared decision-making

Who: Provider team [i.e., MD(s) and APP(s)] and respective care team

Frequency: At least weekly in space to enable discussion with confidentiality of PHI

Key Materials:

• List of OCM patients for physician

• Current status of targeted navigation elements for these patients

• Individual patient status, needs and care plan

• Access to iKnowMed and Practice Management system

Potential Discussion Topics:

• Care and “health” status of all high risk patients

• Phone triage/navigator updates on targeted patients

• Status of recently hospitalized patients & root causes (controllable vs. uncontrollable)

• Lessons learned on recent care decisions

• Review of patients requiring more guidance or compliance to targeted activities

• Opportunities to improve communication on care delivery and related processes within the clinic


The Care Team Measures of Success

• Improved collaboration and coordination between

treating physicians (ie medical oncology/radiation

oncology/surgical oncology)

• Huddle testimonials

• Staff/MD communication surveys

• Rework: Missed orders, redoing orders, order

safety checks

• Clinical trial screening and enrollment

• Staff utilization: APP, RN, SW, MA

• Decrease staff turnover

• Less physician burnout (measure via survey)


Patient Navigation ActivitiesCan be Administrative and/or Clinical

Coordinating appointments with providers to ensure timely delivery

Maintaining communication with patients, survivors, families, and the health

care providers

Facilitating care team performance

Arranging language translation or interpretation services

Facilitating financial support and helping with paperwork

Arranging transportation and/or child/elder care services

Facilitating follow-up services

Community outreach

Building partnerships with local cancer agencies and support groups


Differences between high &

low risk services

Patient Navigation

26

Is patient high risk?

Provide Group Education to complete:- Practice orientation- Chemo/Tx education- Pre-med orders & awareness- Written Tx consent- Access to care orientation - Symptom mgmt. orientation- Psychosocial Distress Screening & ESAS- Patient services (includes language & transport)- Written Advance Directives- Tobacco cessation*- Influenza vaccination or status*- Give Patient summary to patient (Med List and allergies)

No

Provide 1:1 Education to complete:- Practice orientation- Chemo/Tx education & - Pre-med orders & awareness- Written Tx consent- Access to care orientation - Symptom mgmt. orientation- Palliative care assessment- Psychosocial Distress Screening & ESAS- Social work consult & coord. Needs- Patient services (includes language & transport)- Nutrition assessment (MST) & referral- Coord. ACP (MCMW) assessment- Written Advance Directives- Tobacco cessation*- Influenza vaccination or status*- Give Patient summary to patient ( Med List and allergies)

Yes


High Risk Triggers

Triggers identifying high risk chemo patients:

1. Metastatic Lung

2. Metastatic Pancreatic

3. Pts receiving concurrent Chemo + Rad

4. >=75 yrs old + chemo

5. ED or Hospital Visit, except non-emergent, or elective, admission

6. Performance status >/= 2 (ECOG)

7. Health Care Provider referral as high risk

27


Examples of ToolsYear One Year Two Year Three Year Four Year Five

Estimated Number of Unique New Members 2,179 1,551 1,597 1,645 1,694

Estimated Number of Continuing Members 624 1,234 1,243 1,275 1,312

Estimated Number of Covered Months* 12,559 14,088 14,654 15,121 15,580

Estimated Number of New Episodes 2,803 2,784 2,840 2,920 3,007

PBPM Fees $2,009,487 $2,254,126 $2,344,585 $2,419,403 $2,492,864

Shared Savings $0 $313,578 $807,606 $1,393,909

Total Revenue $2,009,487 $2,254,126 $2,658,163 $3,227,009 $3,886,772

Added Staff to Administer the Program (FTEs)

RN I (Hourly) (GL - Clinical) $35,905 $73,965 $73,965 $73,965 $73,965

Advanced Pract Nurse Sr (GL - APP Clinical) $61,418 $126,522 $126,522 $126,522 $126,522

Billing Spec II $21,973 $67,897 $67,897 $67,897 $67,897

Advanced Pract Nurse I $57,299 $177,055 $177,055 $177,055 $177,055

Social Worker (MSW) (GL - Admin) $78,887 $121,880 $121,880 $121,880 $121,880

$0 $0 $0 $0 $0

$0 $0 $0 $0 $0

Total Staffing Cost $255,483 $567,319 $567,319 $567,319 $567,319

McKesson Specialty Costs

Cost for McKesson to handle enrollment $89,331 $63,573 $65,480 $67,445 $69,468

Incremental Loss due to Utilization Changes $291,886 $390,692 $852,477 $1,114,057 $1,402,163

Total Cost $636,699 $1,021,584 $1,485,276 $1,748,820 $2,038,949

Total Revenues $2,009,487 $2,254,126 $2,658,163 $3,227,009 $3,886,772

Total Costs $636,699 $1,021,584 $1,485,276 $1,748,820 $2,038,949

Change to PDP $1,372,788 $1,232,542 $1,172,887 $1,478,189 $1,847,823

Annualized

Revenues

An

nu

aliz

ed C

ost

s

Net Impact

Pt Volume

• Treatment Plan

• Financial

Modeling

• OCM Education

Guide

• Symptom

Management

• Video

Communications


Performance-Based Payment (PBP)

29


A Brave New OCM World:Two-Pronged Payment Approach

Monthly Enhanced Oncology

Services Payment (MEOS)

$160 per month for 6 month episode

Performance-Based Payment

Assessed semi-annually based on

cost-savings and Quality Measures

30

FFS payments continue as usual for all services billed


Requirements to Receive a Performance-Based

Payment (Shared Savings)

1) Actual Costs are lower than the Target Amount

2) Report on all 8 practice-reported Quality Measures to the OCM Registry

3) Implement all Practice Redesign Activities

4) Must achieve an Aggregate Quality Score of at least 30% related to Quality Measures to earn the Performance Multiplier

31

Target

Amount

Actual

CostsPerform.

Multiplier

Performance

Based

Payment


OCM Quality Measures Performance Multiplier based on 12 Quality Measures

Remain set for the first 2 Performance Periods (1 year)

32

Perform.

Multiplier


Quality Measure Phase-In: P4R vs. P4P

Pay-for-Reporting (P4R): requires reporting on sufficient # patients

to earn quality points

Pay-for-Performance (P4P): quality points based on practice

performance compared to quality benchmarks

Generally, each measure will have a max of 10 points available; exception is

first two performance periods, where practice-reported measures have max

of 2.5 points

33

Max Points Per Performance Period

PP1 PP2 PP3

50 60 120

Measure Source Performance Period

1

Performance Period

2

Performance Period

3

Claims-Based P4P P4P P4P

Practice-Reported P4R P4R P4P

Survey Not Included P4P P4P


Calculating the Performance Multiplier

Performance Multiplier based on the Aggregate Quality Score from the practice’s performance on Quality Measures

Practice must achieve AQS >30% to earn Shared Savings(Performance Period 1 > 15 points)

Aggregate Quality Score = Quality Points Earned

Total Quality Points Available

34

Perform.

Multiplier

Aggregate Quality Score

(AQS)

Performance Multiplier

75% - 100% 100%

50% - 74% 75%

30% - 49% 50%

Below 30% 0%


OCM Quality Measures – Monitoring Only Practice reported 8 Quality Measures

35

Measure Description

Chemotherapy intent documented

Advance care plan

Closing the Referral Loop: Receipt of Specialist Report

Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients

Adjuvant chemotherapy is considered or administered within 4 months (120 days) of

surgery to patients

under the age of 80 with AJCC III (lymph node positive) colon cancer

Combination chemotherapy is considered or administered within 4 months (120 days)

of diagnosis for women under70 with AJCC T1c or stage II or III hormone receptor–

negative breast cancer

Trastuzumab administered to patients with AJCC stage I (T1c)- III human epidermal

growth factor receptor 2 (HER2) positive breast cancer who receive adjuvant

chemotherapy

Breast cancer: Hormonal therapy for stage IC–IIIC estrogen receptor/progesterone

receptor (ER/PR)–positive breast cancer


“Oncology Care Model (OCM)” Knowmed

https://knowledge.mckessonspecialtyhealth.com/confluence/display/IKMG1/Oncology+Care+Model+%28OCM%29+Specification


Quality Measure Feedback through Practice Insights

Quality Measures available for review & tracking improvement

View current scores, including filters by site and by physician

Anticipate performance and identify gaps in reporting

37


Focal Points for Pre & Rehab

Engaging patients & providers on keeping patient’s acuity level low

before, during and after treatment

Increased coordination of care between outpatient providers and

hospitals on:

• Right services at the right time for the right patient

• Transitions of care

• Overall outcomes

• Management of total cost or care

Determine what OCM performance measures rehab can move the

dial on and have outcomes data to encourage adoption


Discussion

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Documents

Value Based Care Shift: Oncology Care Model (OCM) · Value Based Care Shift: Oncology Care Model ... The Shift to Value Based Care 3. ... The value based shift emphasizes quality