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Why Pathways? Why Now? “Payers”  Patients  Fully vs. Self Insured Health Plans  Employers / Brokers  Medicare / Medicaid  ACO’s??? Providers  Surgeons.

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Presentation on theme: "Why Pathways? Why Now? “Payers”  Patients  Fully vs. Self Insured Health Plans  Employers / Brokers  Medicare / Medicaid  ACO’s??? Providers  Surgeons."— Presentation transcript:

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2 Why Pathways? Why Now?

3 “Payers”  Patients  Fully vs. Self Insured Health Plans  Employers / Brokers  Medicare / Medicaid  ACO’s??? Providers  Surgeons  Med Onc’s  Rad Onc’s “Suppliers”  Pharma/Biotech  Imaging Vendors  Rad Tech Vendors  Spec Lab Vendors Managers/Tools  Compendia  Formularies  Prior Auth / UM  Specialty Pharmacy  Infusion Centers  Drug Fee Schedules  Guidelines  Pathways Hybrids  Clinically Integrated Networks  Hospital Owned / Affiliated Practices  Multi Disciplinary Practices  Practice Management Co’s  Academic Centers Cancer Landscape 10% of $pmpm Spend

4 Why Pathways? Why Now? Pathways are a proven model for tangibly demonstrating VALUE (Q/C) to your key stakeholders (patients, referring MD’s, hospitals, payers) in the new healthcare milieu And retaining control over decision making for your patients…

5 Agenda Brief history of “Why Pathways at UPMC” What do we mean by Via Oncology Pathways? –How are Pathways developed & maintained? –What diseases / modalities / phases of care are addressed? –How are the Pathways “delivered” and measured? –What are the implementation options? –What is the road map for Pathways for 2012? –Who is using the Via Oncology Pathways today vs. tomorrow? Can we prove success? How can the value of Pathways be monetized? Demonstration of the Pathways Portal

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7 January 2011 Providers

8 UPMC UPMC is a large not-for-profit health system providing both leading health services and insurance in Western Pennsylvania and the surrounding area. UPMC is the region’s largest employer, with 50,000 employees (including 2,800 physicians), 20 tertiary, specialty, and community hospitals, 400 outpatient sites and doctors’ offices, and retirement and long-term care facilities as well as international ventures UPMC Stats Revenue: 7 Billion Assets: 6-7 Billion

9 UPMC Cancer Centers UPMC Cancer Centers is an distinct product line of the UPMC system Organized via a “regional hub and satellite” structure Inpatient and specialized treatment provided at central “hub” while outpatient care is offered at over 40 regional sites Academic and Community Based physicians treating 30,000 new patients per year

10 Needs at UPMC – Rapid expansion of the “UPMC Cancer Centers” brand to 25 sites of Medical Oncology service with a 250 mile geographic spread – Concerns over Quality and Consistency of Care – Internal study revealed significant variability, though mostly within Guidelines – Some care outside of Guidelines – Payers demanding solutions to the rising cancer costs Take charge or lose control…

11 Our Solution: Via Oncology Pathways Continually updated, evidence-based treatment algorithms for most cancer presentations and unique patient co- morbidities, Developed and maintained by the oncologists themselves, Delivered in a point of care, patient specific, interactive decision support tool, Resulting in measurable proof of performance and likely savings in healthcare resources

12 Via Oncology Pathways vs. Guidelines Via Oncology Pathways Guidelines Via Oncology Pathways Guidelines Cancer Incidences Covered Variability Allowed

13 How are Via Oncology Pathways developed and maintained? Physician Disease Specific Committees (18 unique committees) –Two co-chairs for each committee (academic & community based) –Committee participation open to all Via Oncology Pathways physicians Committee Process: –Conflict of Interest Disclosure –Review prior period metrics by patient presentation –Where physicians are going Off Pathway >30%, review reasons cited and what regimen was used instead Consider adding additional “sub-presentations” to achieve goal of 80% coverage –Review new evidence and debate until consensus is established for a single-best

14 What is “single best”? Disease Committees define a single best treatment for each state and stage of disease based upon: First Decision Tier: Efficacy - If there is a clear choice, this is the pathway Second Decision Tier: Toxicity - If efficacy is comparable…pick the treatment with less toxicities to improve QOL and reduce hospitalizations/ED visits Third Decision Tier: Cost - Only if efficacy and toxicities are comparable…pick the lowest cost treatment

15 “On Pathway” Rate Goal: 70-90%

16 How often is Pathway maintenance performed? Quarterly meetings to review new data and change Pathway if needed Software is updated (after MD review) for ALL customers within 2-4 weeks of approved Pathway change by committee For “game changing” new data, call Ad Hoc committee meeting

17 Lymphomas MDS Prostate Lung Breast Colon/Rectal Melanoma Renal Head & Neck Esophageal Myeloma Ovarian Pancreatic Gastric Bladder 95% of all new cancer cases UterineCML Medical Oncology Disease Coverage

18 Modality Coverage Medical Oncology Treatment Infused Chemo & Biologics (Avastin, Erbitux, etc) Orals (Xeloda, Tykerb, etc.) Supportive Care Antiemetics (5HT3’s, Aloxi, Emend) WBC Growth Factors Prognostic Testing (Personalized Medicine) Her2 KRAS OncotypeDX EGFR Advance Care Planning Prompts physician to consider hospice/palliative care for METS Document Treatment Intent and how it was discussed with patient Prompt Physician to consider hospice upon each disease progression Radiation Oncology Treatment Conventional 3D IMRT SRS Brachytherapy

19 11/10/2010 – Peter G. Ellis, M.D. How do we make it easy for the physician to use the pathways? And prove their results???

20 The Pathways Portal Novel Software Application – Point of Care Decision Support Tool Physicians utilize when selecting treatment – Patient Specific / Personalized Interfaced with practice’s demographics and scheduling applications – Easily Implemented Web-Based Application (centrally or locally hosted) – Stand Alone or Integrated with EMR Avoids duplicate entry of treatment orders by physicians

21 The Pathways Portal Focused on Physician Efficiency – Highly intuitive and user friendly Minimal training required Presents the “right patient at the right time” – Provides additional tools to Physician Chemo Order Sets (for non EMR sites) Clinical references and full text articles Patient Education Materials Dose Modification Guidelines Staging references – alerts to physicians each day regarding prior Missed Patients

22 Supporting Clinical Research – Practice specific trials imbedded in Pathways Portal – Trials are always 1 st option in Pathways – Trials are always counted as “On Pathway” – If patient NOT accrued, require “Reasons for Not Accruing” are captured and reported back to PI’s

23 Implementation Options Pathways Treatment Regimens: Via Oncology Standard or Practice Customized Physician Decision Support Tool OR Staff Data Entry Tool Diseases: Some or All Patients: All or Payer Specific Clinical Trials: All, Some, or none Peer Review: On or Off Standalone Application OR Interfaced to EMR

24 Why can’t you get Pathways in an EHR*? EHR Functions * - with the possible exception of iKnowMed

25 2012: Laying down additional lanes!!! Deeper integration with Aria EMR –Inbound clinical data such as Stage, Her2, etc. –Outbound orders Expand pathways for: –G-CSF’s –Prognostic Testing – what should/should NOT be ordered –Surveillance / Survivorship Pathways Phase II of Advance Care Planning “Virtual Tumor Board” within Portal

26 Market Expansion

27 RESULTS: Adherence & Cost Savings

28 Pathways Metrics 9 months ended Sept 30, 2011: 94% Patient Capture Rate (denominator is all patient visits – 280,000 visits per year) 77% “On Pathway” Rate (denominator is all new treatment decisions – 17,000 annual new treatment decisions) – Goal is never 100%...intended to meet the majority of clinical situations but never all… 80-90% is general goal. 100% capture of Reasons for Going “Off Pathway” Most common (30%) is Exceeded Line of Therapy

29 Types of Cost Savings Studies Practice Based Services The 80% of Patients “On” Pathway Practice Based Services The 20% of Patients “Off” Pathways vs. US Oncology Study with Aetna 35% difference in outpatient costs Journal of Oncology Practice January 2010 NSCLC Only Total Cost of Care Patients seen at Pathways Practice Total Cost of Care Patients seen at NON-Pathways Practice vs. Breast & NSCLC Via Oncology Studies with Highmark BCBS

30 Highmark Study Design Two Separate Studies: Breast and NSCLC Population Studied Patients in active therapy (excluded patients in remission) Both commercial and Medicare Advantage with full coverage (e.g., Rx Benefit with Highmark) Analysis completed by Highmark using Highmark claims data Measured Total Cost of Care, not just drugs Two arms Control = non-UPMC patients (40%) Experimental = UPMC patients (60%) Two periods measured 12 months before Pathway implementation 12 months after Pathway implementation (measured months 6-18 to give a 6 mo gap for ramp up)

31 Highmark Cost Savings – Total Cost of Care Highmark/UPMC - Breast Study Results (see details in Appendix) –9% absolute Growth Rate differential 16% growth in Non–Pathways Practices 7% growth in the Experimental Arm – Pathways Practices Highmark/UPMC - NSCLC Study Results (see details in Appendix) –5% absolute Growth Rate differential 6% growth in Non–Pathways Practices 1% growth in the Experimental Arm – Pathways Practices

32 IntrinsiQ Study of NSCLC Drug Costs Large oncology EMR and data analytics company Database of EMR prescribing data for 700 nationally distributed oncologists at very granular level –Regimen –Disease and Stage –Line of Therapy –Performance Status –Clinical Markers (Her2, etc.) Compared for Non Small Cell Lung Cancer: Real world treatment patterns versus UPMC / Via Oncology Pathways Results: –10% savings on Drug Costs if adhered to national Guidelines –40% savings on Drug Costs if adhered to Via Pathways Assuming an On Pathway Rate of 80%, the savings would likely be 32% Cost Savings Study – Drugs Only

33 Up Next – Look for results from Horizon Study Two community based practices in New Jersey Similar study design to Highmark except no radiation costs Results compiled this month by 3 rd party hired by Horizon Shows costs grew in Non-Pathways practices compared to substantial reductions in Pathways practices Working towards publication in early 2012

34 How do you monetize the VALUE of Pathways?

35 Internal Practice Value of Pathways Lower bad debt risk Staying “on” Pathway reduces risk of Payer denials Practice efficiencies through uniformity of care and less variability Staffing productivity Lower inventory holding costs Potential for reducing medical errors Engage patients in shared decision making Stressing accrual to Clinical Tria ls

36 Contracting Opportunities with Payers Gain Share on Savings $1,000 savings to payer is $15 from practice, $485 from Pharma and $500 from hospital Increase existing fee schedule RVU based services Drugs (advise against…) Extend current reimbursement rates Decrease Administrative Burden Eliminate pre-certs / prior auth / Box 19 data Prevent Payer from pulling drugs out of practice Specialty Pharmacy Infusion Centers Reverse rate decreases Payer Steerage to Practice Network Status Benefit design to allow for lower copay/coinsurance Accept case/bundled rates

37 Why Gain Share is difficult… Difficult to measure – requires Payer to roll up costs from variety of systems Results without statistical validity can give false negatives Long timeline for pilot followed by claims runout…then measurement Tends to be a “one year” phenomenon…hard to repeat savings! Payer Unique Issues –Cancer is not their top priority…not even top 3 Most don’t have the information to measure their total $pmpm for cancer –Pathways are the proverbial “elephant in the room” – who at the Health Plan has jurisdiction??? –Some believe that oncologists are already paid too much… –They are not used to outsourcing “UM” to the providers themselves

38 Opportunities with Other Healthcare Entities Patient Centered Medical Homes (PCMH) –Participate directly or become a preferred practice for referrals Design Hospital Private Practice affiliation (co-management) incentive structures through enhanced data capture and monitoring; benchmark performance Form a clinically integrated network (CI) with other oncologists and negotiate single payer contracts Accountable Care Organization (ACO) –Participate directly or become a preferred practice for referrals

39 Why Pathways? Why Now? Pathways are a proven model for tangibly demonstrating VALUE (Q/C) to your key stakeholders (patients, referring MD’s, hospitals, payers) in the new healthcare milieu And retaining control over decision making for your patients…

40 Questions? Discussion…


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