Interdisciplinary leadership in cancer care reform Sandra L Wo ng , MD MS F ACS F ASCO Pro fe sso r and Chair o f Surg e ry T he Ge ise l Sc ho o l o f Me dic ine at Dartmo uth Se nio r Vic e Pre side nt, Surg ic al Se rvic e L ine I nte rim Vic e Pre side nt, Onc o lo g y Se rvic e L ine Dartmo uth-Hitc hc o c k Me dic al Ce nte r
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Learning Objectives • To review major impact of payment reform on cancer care • To connect necessary leadership needs from all disciplines involved in caring for patients with cancer
Outline • Healthcare reform = payment reform • Quality and quality measures • Interdisciplinary teams and leadership
Impetus for healthcare reform • Vast numbers of Americans are uninsured or underinsured • Expand access to healthcare • Health costs are high (and continuing to escalate) • Reduce spending
Cancer expenditures by country All cancers, age >65 Belgium Canada England Germany Netherlands Norway US Inhospital 51.2% 52.1% 41.7% 38.3% 29.% 44.7% 22.2% death ICU adm 17.5% 15.2% 8.2% 10.2% 40.3% (last 180d of life ) Outpt 33.0% 29.1% 28.2% 18.1% 23.7% 38.7% chemo (last 180d of life) Per $15255 $26480 $9216 $24740 $13137 $15849 $26983 capital hosp exp (last 180d of life) Bekelman JE et al. JAMA 2016;315:272-283
National spending on cancer care 2010 2020 (2010 billion (2010 billion dollars) dollars) All sites $124.57 $157.77 Breast 16.50 20.50 Colorectal 14.14 17.41 Lung 12.12 14.73 Prostate 11.85 16.34 Projected 27% increase in costs of cancer care in this decade. Assumes current trends of declining incidence and increasing survival. Mariotto AB et al. J Natl Cancer Inst 2011;103(2): 117-128.
Distribution of costs Cancer services chemotherapy, RT 12% surgery (inc inpt stay) 32% 22% labs, imaging, hospice, other inpt stays other claims 33% Mariotto AB et al. J Natl Cancer Inst 2011;103(2): 117-128.
Interdisciplinary • Medical oncology • Radiation oncology • Surgery oncology care • Palliative care • Medical specialties • Primary care • Nursing • Pharmacy • Pathology • Radiology • Psychiatry • PT/OT • Social Work • Nutrition • Scientists (lab, clinical, informatics) • Healthcare support staff • Policymakers/payers • Industry • Patients
Payment reform: Oncology considerations • Fundamental implication of reimbursement reform: Financial risk moves from payers to providers and the care team • Oncology is a team sport • Decrease variation but keep an eye on innovation and breakthroughs in treatments • Quality must always remain “job one”
Evolution of healthcare reimbursement Global budgets Full capitation ACOs Payment Population spending targets with shared savings Integration Episode bundled payments DRG / PPS (1984) Fee for “Usual and customary” service Integrated health Small MD practices, delivery systems unrelated hospitals Delivery System Integration
Evolution of healthcare reimbursement Global budgets Full capitation Oncology based ACOs ACOs Payment Population spending targets Integration Episode bundled with shared savings payments Episode bundled Oncology medical home payments Clinical pathways DRG / PPS (1984) Fee for “Usual and customary” service Integrated health Small MD practices, delivery systems unrelated hospitals Delivery System Integration
Evolution of healthcare reimbursement Global budgets Full capitation ACOs Payment Population spending targets Integration with shared savings Clinical Episode bundled pathways payments DRG / PPS (1984) “Usual and customary” FFS Integrated health Small MD practices, delivery systems unrelated hospitals Delivery System Integration
Clinical pathways • Standardized, evidence-based protocols for cancer treatment • Decreases variation in chemo treatments • Discourages “buy and bill” model for chemotherapy • Payment schema – Per member per month case management fee – Could include supplemental payments for adherence or achievement of quality benchmarks
Evolution of healthcare reimbursement Global budgets Full capitation ACOs Payment Population spending targets Oncology Integration with shared savings medical home Episode bundled payments DRG / PPS (1984) “Usual and customary” FFS Integrated health Small MD practices, delivery systems unrelated hospitals Delivery System Integration
Oncology Medical Home • Focuses on patient-centered care management • Practice level approach to promote care coordination • Some evidence to suggest lower ED visits, hospital admissions? • Payment schema – Per member per month case management fee to support care coordination across the care team
Evolution of healthcare reimbursement Global budgets Full capitation ACOs Payment Population spending targets Integration with shared savings Episode bundled payments Episode bundled payments DRG / PPS (1984) “Usual and customary” FFS Integrated health Small MD practices, delivery systems unrelated hospitals Delivery System Integration
Episode-based bundled payments • Set payment based on specific set of services over a predetermined period • There is a lot of variation in payments • Providers have flexibility (and incentive) to redirect resources to cost-effective services
Bundled payments • Variation is specific to the disease site, across specialties • Quality is an important driver of variation – Complications are costly • Beware of risks associated with very large or small bundles
Variation in payments for colorectal cancer Abdelsattar et al. J Oncol Pract 2015
ACOs & Shared savings plans • ACO: Group of caregivers that agree to share responsibility and accountability for care of a population of patients • Accountability – Population‐based spending – Defined array of quality metrics (to discourage skimping on care) • Current adoption: approx 400 health systems – Pioneer ACOs (more risk, more reward, more hassle) – Medicare Shared Savings Programs
Success with bundled payments • Understand comparative efficiency across specialties (and thus best opportunities for improvement) • Minimize utilization of discretionary services • Optimize quality • Complications can be costly • Avoid readmissions
Variation in payment for colorectal cancer Abdelsattar et al. J Oncol Pract 2015
Variation in payment for colorectal cancer Abdelsattar et al. J Oncol Pract 2015
Evolution of healthcare reimbursement Global budgets Full capitation Oncology based ACOs ACOs Payment Population spending targets Integration with shared savings Episode bundled payments DRG / PPS (1984) “Usual and customary” FFS Integrated health Small MD practices, delivery systems unrelated hospitals Delivery System Integration
Oncology-based ACOs • Typically population-based patient cohort so excellent care coordination across systems is necessary • Accountability for costs of care in exchange for shared savings • Payments are tied to overall costs and performance on quality measures • Beware of risks associated with one- and two-sided risk models
Value = quality / cost Effective Efficient Safe quantity * price Timely Patient-centered Equitable Source: Crossing the Quality Chasm Institute of Medicine, 2001
Why measure? • To improve care • The short history of hospital quality measurement – Codman’s “end results” cards (1910’s) – Developed M&M conferences – “Forerunner” of The Joint Commission • Today, it’s not whether to measure but how to do it better – Less resistance – Better data quality – Increasing transparency about the data – Still needs to be led by those of us who provide care
Targeting what to measure • Characteristics of a good quality measure – Solid evidence base supports that the metric leads to an improved outcome – The measure actually captures whether care was delivered – The process is in the direct causal pathway of the outcome – No unintended consequences as a result of the metric Chassin et al. N Engl J Med 2010;363:683‐688
Targeting what to measure • Characteristics of a good quality measure – Solid evidence base supports that the metric leads to an improved outcome
Targeting what to measure • Characteristics of a good quality measure – Solid evidence base supports that the metric leads to an improved outcome – The measure actually captures whether care was delivered
Smoking cessation Defined interventions: • Counseling – Individual – Group (proctored, peer) – Telephone • Behavioral therapy VS • Longitudinal programs – Person‐to‐person contact – eHealth programs “You should stop smoking” • Pharmaceutical help – Nicotine replacement – Other Rx
Targeting what to measure • Characteristics of a good quality measure – Solid evidence base supports that the metric leads to an improved outcome – The measure actually captures whether care was delivered – The process is in the direct causal pathway of the outcome
Comparison between patient satisfaction and outcomes Wright et al. JNCI J Natl Cancer Inst 2015;107
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