Achieving the Benefits of Advanced Oncology Management

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Achieving the Benefits of Advanced Oncology
Management
Marybeth Regan, PhD Texas Association of Health
Plans Conference October 22, 2008
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• Dr. Marybeth Regan
• Over 20 years of experience in healthcare
  Payer, Provider and Life Sciences
• 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 06

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Todays Presentation

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

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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
  Today
• New standard calls for whole cancer care,
  10/24/07, USA Today
• An Online Window to Cancer Care, Marketing Health
  Services, Summer 2008

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Oncology Management

• Oncology is a top opportunity area for improving
  careand 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)
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Why Improve Oncology Management?

• Rising Costs
• Nationwide, 78.2 billion in 2006 direct medical
  costs for cancer1
• Costs are growing at 13 annuallydouble the
  overall rate of medical costs1
• 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 outcomes
• 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
NCCNabstracts from NCCN Outcomes Database
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Client ABC Example500,000 Covered Lives
PlanCancer Medical Spending lt 65 Population
250
210m
190m
200
170m
150m
150
Breast Cancer Spend
Top 5 Cancer Spend (excl. Breast)
Annual Spend
100
Cancer Spend
50
0
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
  spend
• Breast cancer expect 1,700 patients equaling
  30,000,000 annual spend
• 1 spend reduction 1,500,000 savings

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Questions

• 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 providers?
• What tools should I make available for
  members/patients?
• How can I adjust my benefit plan design or
  payment strategy to encourage quality care?

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Opportunities for ImprovementBreast Cancer

• 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)
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Granularity Uncovers Potential Cost
SavingsClient ABC Example500,000 Covered Lives
PlanHerceptin use
1,700 patients
4.2m
1,700 patients
4.3
1800
1600
4.2
1400
4.1
1200
400K savings
4
1000
Spend (m)
Patients
3.8m
800
3.9
600
2 reduction in patients utilizing Herceptin
3.8
400
415
425
3.7
200
3.6
0
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

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Opportunities for ImprovementProstate Cancer

• 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 (lt 10
  prostate surgeries) are 70 more likely to have a
  recurrence within 5 years, as compared to
  patients treated by experienced surgeons (gt 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
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Quality

• For every member that is steered from a 1 star
  doctor to a 4 or 5 star doctor, the health plan
  saves 6,251 per year.
• Source Ingenix

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Opportunities for ImprovementColon Cancer

• 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 chemotherapyeven 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. 2
• Cost of colonoscopy 5001000
• vs.
• 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)
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Patient Goals

• Right time
• Right provider
• Right Care
• Right place
• Right cost
• Patient perceives it as right

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Program Components
Wellness Prevention
Consumerism
Care Delivery
Targeting Segmentation
Reach and Engage
Care Management
Condition Management
Benchmarks Metrics
Quality Improvement

Provider Relationship Mgmt

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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 illness1
• 12 of adults representing 17 million people
  said the Internet played a crucial role as helped
  another person cope with a major illness1
• 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 Patients A Mail Survey of
American Society of Clinical Oncology Members
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eHarmony for Doctors
From 34,000 Oncologiststo the one who is right
for me
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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
  mastectomies

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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

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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
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Estimates Treatment Cost for Radical Mastectomy
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Checks Health Savings Account to Validate
Deductible Status

• Ability to check the HSA account prior to
  surgery
• Ability to check status against deductibles
• See what payments have been made or are
  outstanding
• Checks to see if any of her potential medical
  expenses will tax deductible expenses

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Uses PHR as Treatment Progresses

• As treatment options, in this case a Radical
  Mastectomy, the PHR is used on a regular basis to
  track

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Finds User Forums Chat Rooms on Breast Cancer

• Continuing to use the health plan sponsored
  dashboard, a patient can access user forums
  chat rooms with progression through treatment

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Program Components
Wellness Prevention
Benchmarks Metrics
Targeting Segmentation
Reach and Engage
Care Management
Condition Management
Benchmarks Metrics
Quality Improvement

Provider Relationship Mgmt

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Business Intelligence and analytics

• Competitive Advantage

Whats the best that can happen?
Optimization
Predictive modeling
What will happen next?
Analytics
What if these trends continue?
Forecasting / extrapolation
Statistical analysis
Why is this happening?
Alerts
What actions are needed?
Query/drill down
Where exactly is the problem?
Access reporting
Ad hoc reports
How many, how often, where?
Standard Reports
What happened?
Degrees of Intelligence
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.
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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
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Oncology Summary of Costs
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Case Studies of Cost Savings through Oncology
Management Creating Rules and Processes
1 UHC internal data results based on HMO
fully-insured membership
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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
3

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Clinical Data allows a more robust view of
treatment protocols
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Clinical Data Collection

• Collection Methods

• Goal is to create a comprehensive solution to
  reach the targeted providers to request clinical
  data
• Options to collect data
• Fax or online forms
• A Pay-for-Performance Plan
• Through an EMR
• Online provider portal
• An on-line patient portal (like NCCN) (see
  article list)
• Care Coordinator / Disease Management
• Medical Home (see Appendix)
• Results of biopsy

Comprehensive solution
High
Number of Providers Reached
Low
Low
High
Integration into Providers Current Workflow
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Clinical Data Collection
Positive incentives facilitate the collection of
clinical data
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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 outreach

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Metrics and Benchmarking Measures with
Administrative and Clinical Data
Guidelines Index CMS Code Pages TOC Staging,
MS, References - See Appendix)
Invasive Breast Cancer
HISTOLOGY
HORMONE RESPONSIVENESS
HER-2 EXPRESSION
SYSTEMIC ADJUVANT TREATMENT

• Ductal, NOS
• Lobular
• Mixed
• Metaplastic

The National Comprehensive Cancer Network is a
not-for-profit that develops the
gold-standard in cancer treatment guidelines
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Benchmarking

• 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

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Data Analysis Applied to Oncology Management
Plan
Provider
Member
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Steps

• Create a steering committee to develop a game
  plan
• Evaluate data analyze and compare
• Begin with administrative data understand the
  data
• 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

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Solutions

• Consumer Decision Support Strategy is a Must
• Change the consumer experience customer
  empowerment
• 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 performance regionally and/or nationally

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Contact Information

• Marybeth Regan, PhD
• Drmarybethregan_at_aol.com
• 312-497-3000

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Appendix

• 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)

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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

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Patient-Centered Oncology Medical Home
PRACTICE QUALIFICATIONS (Based on NCQA PCC-PCMH)

• Enhanced Access
• Timely Appointment Scheduling especially
  important for cancer patients
• Evening, Weekend and Holiday Hours
• After-Hours Support

Benefits

• Improved Quality at Lower Cost
• Enhanced PatientSatisfaction
• Improved Patient Safety
• Care Continuity Improved Care Transitions
• Improved Practice Profitability and Satisfaction
• Value-based Payment
• Simplified and Coordinated Health Care Experience

• Care and Chronic Condition Management
• Specialty Referral Coordination and Tracking with
  Oncology being the primary driver
• Disease and Case Management Enrollment

• Team Care
• Physician-directed team both in and outside of
  the practice setting key for outpatient
  chemotherapy
• Management of Care Transitions across the Health
  Care Continuum

• Performance Measurement, Assessment Improvement
  
• Practice in accordance with clinical evidence
• Performance Evaluation Based on Medical Best
  Practices
• Measurement of Clinical Processes and Outcomes

ENABLING TECHNOLOGY CLINICAL SUPPORT

• Technology
• Tools
• Point of Care (POC) Registry
• Personal Health Record
• ER POC Data EventNotification
• Electronic Prescriptions
• Physician Dashboard

• Care Coordination
• Management Support
• Medical Home Care Advocate
• Educational Materials
• Patient Activation Tools
• Practice Redesign Support

• Care
• Access
• 24-Hour Nurse-Line
• Group Visits
• eConsultations