Making Disease Treatment Standardization Work in Community Practice

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Making Disease Treatment Standardization Work in
Community Practice

• Jim Koeller, M.S.
• Professor
• University of Texas at Austin the Health
  Science Center, San Antonio

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Expectations For 2007?

• The bottom line
• Things will get worse (revenues will tighten even
  more), we are not close to the bottom yet.
• Not everyone will survive or probably need to
  survive (this is somewhat Darwinian the strong
  will survive)
• You do not have to change, but their Will Be
  consequences for your lack of action!
• You can control much of your own destiny, or much
  of it will controlled for you.
• Those who survive will be leaner, stronger, more
  efficient and just better! (look at the dialysis
  model)

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Expectations For 2007?

• Core reimbursement shifts continue to change the
  oncology business model (drug vs. service
  dependence)
• CMS practice expense (some decreases)
• Imaging procedure cuts (technical component to be
  paid at OPPs rate)
• Pt shifting to increase?
• ASP remains (GAO, MedPac, OIG all think it
  works!)
• Stabilizing quarterly rate fluctuations
• Continuing issues 2 quarter fee increase lag
  and exclusion of the prompt-pay discount

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Expectations For 2007?

• Commercial payers
• Continue to switch to ASP-based payment (BCBS)
• Continued push for specialty pharmacy use
• Will CAP survive?
• 300 physicians (22 oncologists)
• Demonstration project discontinuation
• Was considered a precursor to P4P initiatives
• Practices to continue work on ? efficiency,
  controlling costs and expanding revenue sources
• More emphasis on quality, P4P, transparency
• Making costs and MD-to-MD quality comparisons
  available to all
• Most clinics have done OK in 2006

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The New Face of Oncology

• Oncology is being moved in the direction of
  demonstrating quality of care, P4P, and
  transparency..
• Transparency is becoming the new theme
• ie., making cost and physician-to-physician
  quality comparisons available
• Data will become KING (which makes EMR a
  necessity)
• Note just having the data will not be enough!
• Everyone cannot get everything demonstrating
  that you can control the use of resources will be
  critical
• You will need to format your data to tell this
  story
• Will need to be able to demonstrate a control of
  resources and still able to provide quality
  patient care
• Benchmarking will become critical

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Pay For Performance - P4P(ie., Quality Measures)

• Most of this to date has been hospital-based
• Probably over 120 different P4P programs now
• Most of these are medicare/medicaid (10
  different demonstration initiatives)
• Reporting Hospital Quality Data for Annual
  Payment Update (RHQDAPU), has 21 quality measures
  that if not reported result in a 2 payment
  decrease
• Premier Hospital Quality Initiative involved 272
  hospitals and 34 quality indicators for 5
  clinical conditions providing a 2 bonus for the
  top stratum
• Community-Based
• 3-year CMS demonstration project with 10 large
  (200 docs). The goal for now is to save money

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Pay For Performance - P4P(ie., Quality Measures)

• Quality care measuring in oncology
• CMSs 2005/2006 demonstration projects dealt with
  side effects and adherence to guidelines
• Most agree that true quality measures should
  address clinical outcomes
• Cancer pt outcomes depend on P.S, type grade of
  tumor, metastases, treatment type and generally
  are measured only over a longer period of time
• This will require documentation and extensive
  data capture - EMR
• Until that time we expect CMS to focus on
• Utilization and cost management
• Narrowly focused effectiveness of treatment
• Pt. safety
• Adverse events
• To report on such measures means clinics will
  need to define treatment plans in terms of
  standardized regimens

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What are Community Practices Doing Now?

• Benchmarking can take on many identities
• For all in tense and purposes, practice
  benchmarking is in its infancy
• Manages have benchmarked macro practice
  performance measures for some time
• Patient visits
• New patients
• Patients treated
• Charge and revenue information (by category)
• Some electronic drug boxes are providing drug use
  information
• I am unaware of the existence of a sophisticated
  clinical database (this isnt to say the data
  doesnt exist in some cases)
• Presenting clinical data by disease type which
  would include demographics, treatment, toxicity
  and specific end-point measures

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So, what major changes to how you are
practicing oncology do you make?Where do you
start
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Practice Changes

• The community practices core business will
  become the infusion center will need to put
  more emphasis on it...
• Work efficiency, overhead, , personnel issues,
  evaluating services provided, looking at new
  services to provide (diversifying revenue
  streams)
• Documenting quality of care (transparency)
• EMR is necessary
• Standardization of chemo regimens will ensure
  consistent drug use
• Standardizing treatment strategies for common
  cancers (ensures consistent patterns of drug use)
• Must be able to demonstrate control of resources
  with a positive outcome

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Understanding the Basis of Your Practice

• In Community Hospital Oncology Practice,
• chemotherapy infusion
• is becoming the oncologists
• Procedure.

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Understanding the Basis of Your Practice

• Business 101
• What is the cost of your unit of business
  (procedure)
• Your procedure is the chemotherapy infusion
• What revenue is generated by that unit of
  business
• Most businesses are allowed to set their price to
  make a margin (which covers costs and provides a
  profit)
• For oncology, your revenue amount is set for
  you!

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Understanding the Basis of Your Practice

• Understand the cost of your procedure Infusion
• Cost per hour of infusion chair time
• Practice overhead (fixed)
• Nursing time
• Support personnel (LVN,MA)
• Chemotherapy preparation
• Typical chair per hour cost 68 - 300

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A Few Suggested Basic Rules

• Put more emphasis on your infusion center
• A new pt. Should not be treated on the 1st-day
  visit
• Nurses should not education in the infusion chair
• 75 of pts. need not be treated between 1030am
  130pm
• Infusion Injections should be two separate
  processes
• Nurses should not mix chemotherapy (technicians)
• Pts. should not spend 2 hrs. in the clinic to
  receive a 10 sec. injection
• Nurses need to control the primary care nursing
  they perform at the infusion chair
• Lost drug charges need to stop
• When possible, have an expert manage your
  chemotherapy

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Treatment Variability in Practice Today

• If you provide a single patients case to 10
  oncologists, how many different treatment plans
  would be suggested? (at least 10 probably)
• Physicians typically treat by an N1.
• Physicians do not process data by groups of
  patients
• Do physicians really know what happens to a
  cohort of patients they treat?
• What happened to the last 50 metastatic breast
  cancer ladies you treated as a group?
• Physicians generally do not have organized
  clinical databases on treated cohorts of patients

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Standardized Regimen Orders

• Create standardized regimen recipes (including
  pre-meds)
• Helps control nurse administration variation
• Which has been measured to exceed 200
• Sets a standard for the specific administration
  method and time for each agent
• All AC regimens in your practice should basically
  be given the same, and so on
• The top 40 regimens make up 80 of whats given

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The Hypothesis Is

• If you provide the right information on a
  specific cohort of patients including their
  treatment to those who provide the care, they
  will make the appropriate treatment decisions.
• Koeller - 1991

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Making the Right Care Decisions

• Treatments for the primary diseases of breast,
  lung and colon cancer have become increasingly
  complicated
• Newer active agents
• Including targeted therapy
• More lines of therapy
• More options for each line of therapy
• Many more supportive care options
• The need to take into account patient toxicity
  issues (including QOL)

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Why is Controlling Disease Treatment So Important?

• Current community practice has shown a variation
  in treatment approach of over 400 (resources
  utilized) for advanced Lung, Breast and Colon
  cancer
• Variation causes significant treatment
  inefficiencies
• Infusion and injection numbers and frequencies
  are established by individual physician practice
  patterns
• By being more consistent with disease treatment
  approaches, a clinic can have a better handle and
  control over the number of infusions injections
  administered
• What diseases do you manage Advanced NSCLC,
  Breast, Colon, Ovarian, Prostate cancer
  (roughly 65 of a clinics pts).
• Koeller, et al. Data on file, 2006.