ACOs, Oncology Medical Homes and Strategic Options for Oncologists

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1 ACOs, Oncology Medical Homes and Strategic Options for Oncologists Presented by: Michael L. Blau, Esq. Foley & Lardner LLP Attorney Advertising Prior results do not guarantee a similar outcome Models used are not clients but may be representative of clients 321 N. Clark Street, Suite 2800, Chicago, IL

2 Rate of Growth of Health Care Spending 2

3 Health Care Spending 3 Average spending on health per capita ($US PPP) 16 Total expenditures on health as percent of GDP United States Germany Canada Netherlands New Zealand Australia United Kingdom Note: $US PPP = purchasing power parity. Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

4 Country Rankings Quality and Cost AUS CAN GER NETH NZ UK US OVERALL RANKING (2010) Quality Care Effective Care Safe Care Coordinated Care Patient-Centered Care Access Cost-Related Problem Timeliness of Care Efficiency Equity Long, Healthy, Productive Lives Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837 * $2,454 $2,992 $7,290 4 Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

5 Oncology Responsible for Sizable and Growing Share of Costs 5 $125B Spending on cancer services in 2010 Base Case: Forecast holds incidence, survival and costs steady $207B Forecast #1 Forecast spending in 2020 Forecast #2 Trend Incidence and Survival: Assumes incidence and survival trends will continue as observed in last years of data Forecast $157B spending in 2020 Cost Increase: 5% increase in costs in initial and last year phases of treatment $155B Forecast #3 Forecast spending in % 10-year Growth rate 26% 10-year Growth rate 24% 10-year Growth rate Source: Mariotto, AB et al, Projections of the Cost of Cancer Care in the United States: , J Natl Cancer Inst, 2011; 103: 1-12 Slide Source: The Advisory Board Company, 2011 Oncology Roundtable

6 Oncology Responsible for Sizable and Growing Share of Costs 6 Provenge for the Treatment of Prostate Cancer $93 K 25,000 Months median survival benefit Cost per treatment course Estimated number of eligible patients 3.6 $120 K 8,700 Median, survival benefit 1 Indicated for hormone refractory metastatic prostate cancer. 2 Indicated for unresectableor metastaicmelanoma. Provenge for the Treatment of Melanoma 2 Cost per treatment course Number of deaths each year from melanoma Source: Chambers, James D and Peter Neumann, Listening to Provenge What a Costly Treatment Says About Future MeidicarePolicy, NEJM, April 6, 2011, available at: https://healthpolicyandreform.nejm.org/?p=1412&query=toc; Oncology Roundtable interviews and analysis. Slide Source: The Advisory Board Company, 2011 Oncology Roundtable

7 Oncology Responsible for Sizable and Growing Share of Costs 7 Breast Biopsies Imaging in Prostate Cancer Chemotherapy in Metastatic Colon Cancer 30% Breast biopsies that are surgical 36% Low-risk patients receiving unnecessary MRI, CT or bone scan 13% Receiving nonevidence-based chemotherapy 10% Accepted benchmark 49% Medium-risk patients receiving unnecessary MRI, CT or bone scan $2 M Excess spending across cohort of 140 patients 2,000 Women receiving unnecessary surgery 39% High-risk patients not receiving scanning when it is indicated $14,285 Cost per patient $37 M Costs per year $35 M Excess costs per year Source: GutweinLG et al, Utilization of Minimally Invasive Breast Biopsy for Evaluation of Suspicious Breast Lesions, American Journal of Surgery, 2011, Feb 2; Laino, Charlene, Prostate Cancer: Radiographic Imaging Scans Often Inappropriately Used, Oncology Times, March 20, 2011; de Souza, JA, et al, Utilization and Costs of Non- Evidence Based AntineoplasticAgents in Patients with Metastatic Colon Cancer, presented at ASCO Slide source: The Advisory Board Company, 2011 Oncology Roundtable

8 8 ACO Introduction ACA and ACOs ACA Creates ACO buzz Proposed Rule Dead on arrival Final Rule Resuscitates ACOs Better economics Greater flexibility Less administrative burden Waivers less legal risk Supreme Court Decision get on with it Presidential politics

9 Supreme Court Decision Constitutional issues are individual mandate and Medicaid expansion Individual mandate is constitutional under Taxing Clause of Constitution, even though Congress assessed a penalty, and not a tax on those who fail to purchase insurance Saves unconstitutionality under Commerce Clause Medicaid expansion is unconstitutional under Spending Clause of Constitution because it would impermissibly coerce states to participate by penalizing those who don t by withholding federal funding of their existing Medicaid programs Leaves ACA almost wholly intact except participation in Medicaid expansion is optional Consequences: Potent Presidential campaign issue Leaves 5-10 million uninsured Creates significant charity care issue, particularly for safety net hospitals 9

10 10 ACA Accelerates Provider Integration ACA reinforces and accelerates private market changes in payment/delivery Coverage of 25 million (?) uninsureds Less payment per unit of service Reward value instead of volume Value based purchasing, shared savings, gainsharing, bundled payments, EOCs, capitation Coordinate care among and across providers ACOs, medical homes, home based chronic care management, community health teams, health care innovation zones Oncologists as owners/decision-makers v. vendors

11 11 ACOs The Legislative Framework Triple aim: patient-centric care, increase quality, reduce cost Align provider incentives toward population management and health through shared savings opportunity Voluntary participation by providers/patients Minimum of 5,000 Medicare beneficiaries ACO participating providers continue to be paid by Medicare on a FFS basis

12 12 ACOs The Legislative Framework Benchmark set for expected Medicare Part A&B spending for beneficiaries, based on historic cost in 3 years preceding ACO contract, adjusted annually for the trend in Medicare cost growth ACO is paid a portion of Medicare cost savings above a MSR, if quality standards are met Cost savings are allocated by ACO to participants, over and above FFS payment

13 13 Will There Be an Oncology Led ACO? No beneficiary assignment based principally on PCP services Two step process permits limited recognition of specialist services First step based on plurality of primary care services (allowed charges) provided by PCPs in ACO No assignment if plurality provided by a PCP who is not in an ACO Second step only if no historic (trailing 12 mo) PCP services assigned based on primary care services provided by any other ACO professional, including any oncologist during year Preliminary prospective determination, quarterly prospective updates, with final assignment at each year-end

14 14 Changes In Final Rule Financial provisions make it more likely that ACOs will generate shared savings and receive a larger portion of savings Track 1 no downside risk in one-sided model during initial term; first dollar sharing in up to 50% of savings (2% CMS take eliminated) to a cap of 10% of expenditures (up from 7.5%), if MSR (2 to 3.9%) and quality performance standards are met (at least one/70% in each domain) Downside risk, if renew, but no obligation to renew

15 15 Changes In Final Rule Financial provisions (con t) Track 2: Two sided model with first dollar sharing in up to 60% of savings up to a 15% (instead of 10%) cap Losses shared at not more than 60% (rather than 1 minus shared savings rate) rate, to a cap of 5% (Y1), 7.5% (Y2), 10% (Y3) MSR/MLR of 2% before shared savings or loss Elimination of 25% withhold to secure loss repayment

16 ACOs and Counting 32 Pioneer ACOs as of January 1, in TX (North Texas ACO and Seton Health Alliance) 27 MSSP ACOs as of April 1, in TX (Accountable Care Coalition of Texas (Houston)) 87 MSSP ACOs added July 1, in TX (BHS Accountable Care; Essential Care Partners; Memorial Hermann ACO; Meridian Holdings; Methodist Patient Centered ACO; Physicians ACO; Texoma ACO) IDSs with PCP base v. Physician organizations Who will vendorize who

17 17 Jury Is Out On Prospects Physician Group Practice (PGP) demo experience 8 of 10 participants did not receive any performance payments in year 1 6 of 10 received no payments in year 2 5 of 10 received no payments in year 3 Participants invested $1.7 million on average, in the first year alone None recovered their investments Source: Chambers, James D and Peter Neumann, Listening to Provenge What a Costly Treatment Says About Future MeidicarePolicy, NEJM,April 6, 2011, available at: https://healthpolicyandreform.nejm.org/?p=1412&query=toc; Oncology Roundtable interviews and analysis. Slide Source: Matt Brow, Vice President of Government Relations, and Public Policy McKesson Specialty Care Solutions/US Oncology: The Role of Oncology in Accountable Care Organizations June 8, 2011

18 18 Top Oncology Concerns No or limited role in ACO governance --Each ACO participant (with a separate TIN) must be represented and have meaningful participation in governing body decisionmaking At best, Oncology will be one among many ACO participants 18

19 19 Top Oncology Concerns Oncology has higher cost patients; Oncology less likely to contribute toward cost savings Median cost of oncology care is $111K/patient Outlier cap under MSSP is 99 th percentile (approx. $100K) Growing cost of new chemo drugs/rt technology Patients who develop cancer during the measuring period may increase costs against benchmark and reduce likelihood of ACO realizing cost savings Benchmark is set prospectively, and is not adjusted for changes in health status or acuity of actual beneficiaries during 3 year term of MSSP (comparing different populations) Risk that historical cost experience for patients will not be predictive of future costs Could create incentive to avoid including oncologists/cancer patients in the ACO

20 Top Oncology Concerns 20 Substantial ACO costs and risks with no assurance that oncologists will be allocated a fair share of any rewards; ACO costs include: Human resources, including an experienced Executive Director, a full-time Medical Director, and a Compliance Officer Infrastructure that allows the ACO to collect quality/cost data, provide feedback across the entire ACO, and report to CMS (e.g., common IT platform) Policies and procedures clinical guidelines, compliance plan and training, physician directed QA/process improvement processes, clinical integration program, corrective action process, CMS data use agreement, distribution of shared savings Patient-centeredness program Reserve requirement (1% of expenditures) 20

21 21 Top Oncology Concerns Cross-cutting alternative payment and FFS incentives create burden and confusion No oncology-specific metrics (other than screening); no necessary commitment to track and measure quality of cancer care within ACO 33 quality measures across 4 domains; no shared savings or reduced shared savings if quality measures not met Virtually no health care system today measures this many standards Oncologists may be less likely to be allocated a fair share of any shared savings realized Each ACO must specify its method of allocating and distributing shared savings dollars, and all specialties do not need to be included or treated equally 21

22 22 Top Oncology Concerns Could incent participating oncologists to avoid higher cost new (and better) oncology diagnostics and therapeutics E.g., genetic testing/personalized medicine Patient freedom to choose providers and prohibition on requiring in-network referrals limit ability to coordinate care and manage cost Beneficiaries can opt-out from CMS claims data sharing, and if they do, oncology care cannot be managed across providers/sites of care

23 23 Top Oncology Concerns MSSP may incent participating providers to stint on care, with adverse impact on quality Will there be an ROI and what happens to the ROI if and when payments are re-based after the initial contract term?

24 24 ACO Contracting: Key Terms Service level Payment method and rate Timing of payments Upside/downside risk? Performance standards/performance payments Timing of reconciliation/final payment Deep pocket guarantee? Term/termination Restrictive covenants Compliance with ACO requirements (e.g., can t require innetwork referrals) Access to records and audit right Dispute resolution process

25 25 Conclusions and Strategic Options for Oncologists

26 26 Strategic Options For Oncologists Do nothing Become an ACO participant in a local/regional ACO and obtain proportionate role in governance/decisionmaking Apply to CMMI for an innovation grant for an oncology initiative Form an oncology supergroup under a single tax id number (holding company or divisional model) Form strong oncology IPA for risk-contracting Join a sizable multi-specialty group with a strong primary care base and become a physician-centric ACO/Medical Home Form an Oncology Medical Home and try to be indispensible to all ACOs and PCMHs

27 27 Oncology Medical Home Consultants in Medical Oncology (PA) NCQA Level 3 Oncology Medical Home Care coordination; value and evidencebased, pro-active care Hand-off from PCMH when primary diagnosis is cancer, through survivorship Patient registry Nurse telephone triage

28 28 Oncology Medical Home Standardization of patient assessment, treatment protocols, collection of data, documentation, patient navigation Emergency department visits per chemo patient reduced from 2.6 in 2004 to 0.91 in 2010 Hospital admissions per chemo patient reduced to 0.6 Documentation turnaround reduced from 28 to less than 1 day End-of-life care planning reduces chemo use/visits by 12% and increase in the average hospice LOS from 26 days to 32 days

29 29 Oncology Medical Home Measurable patient outcomes not adversely affected Key is getting payors to pay more for fewer services/better value Can t be too far ahead or behind reimbursement Add membership fee for patient navigation/care management services? Add sister research and education foundation?

30 Other Strategic Options For Oncologists Clinically integrate with a Hospital/IDS/ACO (e.g., through PSA/Co-Management arrangements) Sell practice and become employed by a Hospital/IDS/ACO Partner with a Practice Management Company, HIT Company, or Private Equity Company Become part of a staff model HMO or payor affiliate Payor/provider convergence due to MLR limitations and respective competencies Use data analytics to experiment with care transformation alone and/or with preferred partners to define and deliver a new value proposition 30

31 31 Care Transformation Opportunities Prevention Screening Diagnosis and Treatment Planning Smoking cessation, diet and lifestyle management Pharmaceutical prevention in prostate and breast Undertapped opportunity Opportunity to improve outcomes through earlier diagnosis Unlikely to destroy demand High false positive rate in some screening modalities may add costs Providing timely, streamlined access to diagnosis and treatment plan Ensuring accurate diagnosis Multidisciplinary treatment planning Active patient engagement in treatment planning process Care management/patient navigation Treatment Palliative Care End of Life Survivorship Ensuring evidence-based care Appropriate enrollment in clinical trials Principled alignment of patient and provider acuity Active management of side effects to minimize ED, IP utilization After hours care Proactive utilization of palliative care and symptom management Source: Oncology Roundtable interviews and analysis. Establish treatment goals, update frequently Early engagement in end-of-life planning Timely referral to hospice Creation of treatment summary and survivorship care plan Consistent screening for secondary cancer and recurrences Active management of late effects

32 32 QUESTIONS?

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