Making Disease Treatment Standardization Work in Community Practice

1. Making Disease Treatment Standardization Work in Community Practice Jim Koeller, M.S. Professor University of Texas at Austin & the Health Science Center, San Antonio

3. 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…)

4. 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 OPP’s 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

5. 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…

6. 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

7. 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

8. Pay For Performance - P4P(ie., Quality Measures) • Quality care measuring in oncology • CMS’s 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

9. 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 isn’t to say the data doesn’t exist in some cases) • Presenting clinical data by disease type which would include demographics, treatment, toxicity and specific end-point measures

10. So, what major changes to how you are ‘practicing’ oncology do you make?Where do you start…

12. Practice Changes • The community practice’s 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

13. Understanding the Basis of Your Practice In Community & Hospital Oncology Practice, chemotherapy infusion is becoming the oncologists ‘Procedure’.

14. 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!

15. 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+

16. 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 10:30am & 1:30pm • 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

17. 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 N=1. • 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

18. 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 what’s given

20. 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

21. 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)

22. 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.