Practice and Hospital Site of Service Costs

1. Practice and Hospital Site of Service Costs Understanding and Utilizing Comparative Data Community Oncology Alliance Managed Care Digest Series®Richard Frye, Ph.D., General Editor

2. National Patient Counts, 2011

3. Data Methodology: IMS Patient Claims Data The IMS Health analysis of claims data focuses specifically on prostate and colorectal cancer. Information was obtained through the use of the standard Healthcare Common Procedure Coding System (HCPCS) utilizing J-codes for the billing of chemotherapy and other forms of treatment. These data are obtained from two proprietary databases that are maintained by IMS Health. One database uses claims data from physicians’ offices and clinics (CMS 1500); the other is based on hospital outpatient charges (charge data master or CDM). IMS Health uses algorithms to project its data to national and regional levels. These two data sets can be viewed in parallel but not commingled. The data reporting period is the full calendar year of 2011, with a look back through the patient’s medical history to assign cancer diagnoses. Patients diagnosed and treated for prostate or colorectal cancer were tracked if they received chemotherapy or hormone therapy.

4. Regional Breakdown

5. Percentage of Colorectal Cancer Patients, by Age Group, 2011

6. Percentage of Prostate Cancer Patients, by Age Group, 2011

7. Percentage of Colorectal Cancer Patients, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations.

8. Percentage of Prostate Cancer Patients, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations.

9. Percentage of Colorectal Cancer Patients with Metastatic Cancer

10. Percentage of Prostate Cancer Patients with Metastatic Cancer

11. Percentage of Colorectal Cancer Patients with Metastatic Cancer, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations.

12. Percentage of Prostate Cancer Patients with Metastatic Cancer, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations.

13. Average Number of Cycles for Colorectal Cancer Patients, by Age Group, 2011

14. Average Length of Therapy (Days) for Colorectal Cancer, by Age Group, 2011

15. Average Number of Cycles for Prostate Cancer Patients, by Age Group, 2011 NOTE: Some regimen metric data were unavailable for the selected regions.

16. Average Length of Therapy (Days) for Prostate Cancer Patients,by Age Group, 2011 NOTE: Some regimen metric data were unavailable for the selected regions.

17. Average Number of Cycles for Colorectal Cancer Patients, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations.

18. Average Length of Therapy (Days) for Colorectal Cancer Patients, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations.

19. Average Number of Cycles for Prostate Cancer Patients, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations.

20. Average Length of Therapy (Days) for Prostate Cancer Patients, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations. NOTE: Some hospital outpatient regimen metrics were unavailable for the selected regions.

21. Average Annual Charges, by Age Group, Colorectal Cancer, 2011 • NOTE: Regarding Medicare reimbursement, hospitals and physicians' offices use the same billing codes, but rates differ. Medication charges incurred in a physician's office are usually paid at contracted rates, which can be lower than billed charges. Hospitals generally pay less for chemotherapy and are reimbursed at lower rates, but receive fees that include average sales price (ASP) + 6% in the physician office setting. Separately paid drugs in hospital outpatient departments are expected to be reimbursed at ASP + 4% in 2013. • Physician office claim charges include only those drug charges administered in the office setting (i.e., chemotherapy, supportive care, steroids). If there is a lab component, this would also be captured, along with physician office administrative service charges. • Hospital outpatient charges incorporate all aspects of care, including direct (i.e., pharmacy, imaging, administrative provider services) and indirect (i.e., financial services, information technology, operations expenses) overhead.

22. Average Annual Charges, by Age Group, Prostate Cancer, 2011 • NOTE: Regarding Medicare reimbursement, hospitals and physicians' offices use the same billing codes, but rates differ. Medication charges incurred in a physician's office are usually paid at contracted rates, which can be lower than billed charges. Hospitals generally pay less for chemotherapy and are reimbursed at lower rates, but receive fees that include average sales price (ASP) + 6% in the physician office setting. Separately paid drugs in hospital outpatient departments are expected to be reimbursed at ASP + 4% in 2013. • Physician office claim charges include only those drug charges administered in the office setting (i.e., chemotherapy, supportive care, steroids). If there is a lab component, this would also be captured, along with physician office administrative service charges. • Hospital outpatient charges incorporate all aspects of care, including direct (i.e., pharmacy, imaging, administrative provider services) and indirect (i.e., financial services, information technology, operations expenses) overhead.

23. Average Annual Charges, by Payer, Colorectal Cancer, 2011 • 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations. • NOTE: Regarding Medicare reimbursement, hospitals and physicians' offices use the same billing codes, but rates differ. Medication charges incurred in a physician's office are usually paid at contracted rates, which can be lower than billed charges. Hospitals generally pay less for chemotherapy and are reimbursed at lower rates, but receive fees that include average sales price (ASP) + 6% in the physician office setting. Separately paid drugs in hospital outpatient departments are expected to be reimbursed at ASP + 4% in 2013. • Physician office claim charges include only those drug charges administered in the office setting (i.e., chemotherapy, supportive care, steroids). If there is a lab component, this would also be captured, along with physician office administrative service charges. • Hospital outpatient charges incorporate all aspects of care, including direct (i.e., pharmacy, imaging, administrative provider services) and indirect (i.e., financial services, information technology, operations expenses) overhead.

24. Average Annual Charges, by Payer, Prostate Cancer, 2011 • 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations. • NOTE: Regarding Medicare reimbursement, hospitals and physicians' offices use the same billing codes, but rates differ. Medication charges incurred in a physician's office are usually paid at contracted rates, which can be lower than billed charges. Hospitals generally pay less for chemotherapy and are reimbursed at lower rates, but receive fees that include average sales price (ASP) + 6% in the physician office setting. Separately paid drugs in hospital outpatient departments are expected to be reimbursed at ASP + 4% in 2013. • Physician office claim charges include only those drug charges administered in the office setting (i.e., chemotherapy, supportive care, steroids). If there is a lab component, this would also be captured, along with physician office administrative service charges. • Hospital outpatient charges incorporate all aspects of care, including direct (i.e., pharmacy, imaging, administrative provider services) and indirect (i.e., financial services, information technology, operations expenses) overhead.

25. Practice and Hospital Site of Service Costs Site of Service Case Study for Florida

26. Percentage of Florida Cancer Patients, by Age Group, 2011

27. Percentage of Florida Cancer Patients, by Payer 1 Includes HMOs, PPOs, point-of-service (POS) plans and exclusive provider organizations.

28. Percentage of Florida Cancer Patients with Metastatic Cancer

29. Average Length of Therapy (Days) for Florida Cancer Patients, by Age Group, 2011 NOTE: Some regimen metric data were unavailable for the selected regions.

30. Annual Charges for Florida Cancer Patients, by Age Group, 2011 • NOTE: Regarding Medicare reimbursement, hospitals and physicians' offices use the same billing codes, but rates differ. Medication charges incurred in a physician's office are usually paid at contracted rates, which can be lower than billed charges. Hospitals generally pay less for chemotherapy and are reimbursed at lower rates, but receive fees that include average sales price (ASP) + 6% in the physician office setting. Separately paid drugs in hospital outpatient departments are expected to be reimbursed at ASP + 4% in 2013. • Physician office claim charges include only those drug charges administered in the office setting (i.e., chemotherapy, supportive care, steroids). If there is a lab component, this would also be captured, along with physician office administrative service charges. • Hospital outpatient charges incorporate all aspects of care, including direct (i.e., pharmacy, imaging, administrative provider services) and indirect (i.e., financial services, information technology, operations expenses) overhead.

31. Practice and Hospital Site of Service Costs, for Prostate Cancer, by Specialty

32. Percentage of Prostate Cancer Patients, by Specialty, Physician Office Setting, 20111 1 Specialty data were available for the physician office setting only. 2 “Other” includes internal medicine, radiation oncology, family medicine, geriatric medicine and others.

33. Length of Therapy and Number of Cycles, by Specialty, Prostate Cancer, Physician Office Setting, 20111 1 Specialty data were available for the physician office setting only.

34. Length of Therapy and Number of Cycles, by Specialty, Metastatic Prostate Cancer, Physician Office Setting, 20111 1 Specialty data were available for the physician office setting only.

35. Average Annual Charges, by Specialty, Metastatic Prostate Cancer, Physician Office Setting, 20111 1 Specialty data were available for the physician office setting only.

36. Questions