Building a Regional Cancer Care Collaborative: OHSU-Legacy Cancer Collaboration

2. Building a Regional Cancer Care Collaborative Presented by: • Michael L. BlauFoley & Lardner LLPmblau@foley.com617-342-4040 • Cory JonesCatholic Health Initiativescoryjones@catholichealth.net720-568-3704 • Tony Melaragno, M.D.Legacy Good Samaritan Medical Centertmelarag@lhs.org503-413-6875 • William T. Sause, M.D.Intermountain Health Care, Inc.William.sause@imail.org801-507-3838

3. Introduction Presented by: Cory JonesCatholic Health Initiativescoryjones@catholichealth.net720-568-3704

4. The OHSU-Legacy Cancer CollaborativeA Regional/Community Based Program Presented by: Tony Melaragno, MD VP Behavioral Health and Oncology Services Legacy Health tmelarag@lhs.org 503-413-6875

5. OHSU-Legacy Cancer Collaboration • Began July 2013 • Includes all radiation oncology for both organizations – 5 sites • Includes all community medical oncology and infusion in 5 counties • 6 current sites • Co-managed by both organizations with an Executive steering committee with equal representation by both parties • Finances fully integrated and net income distributed based on baseline organizational contributions

6. OHSU-Legacy Cancer CollaborationWhat Drives Success of Partnership • Both Parties Bring Key Ingredients to the collaboration • OHSU • Academic Institution • The Knight Cancer Institute with expertise and vast financial resources • Community network of strong Hematology Oncology providers • Access to Personalized Medicine and Advanced Research protocols

7. OHSU-Legacy Cancer CollaborationWhat Drives Success of Partnership • Both Parties Bring Key Ingredients to the collaboration • Legacy Health • Regional system with multiple hospitals and a large network of Primary Care clinics • Strong tradition of surgical oncology, especially breast specialists and innovation in radiation oncology • Continuous growth in volume of cancer diagnoses • Long history of Commission on Cancer Accreditation as a System (with commendation)

8. OHSU-Legacy Cancer CollaborationWhat Are the Challenges • Collaborators but still Competitors • Fear of the “University” stealing patients • Realigning Existing Referral Patterns • Certain Operational changes by one partner may need to be vetted with the other • Educating individual site staffs that it’s okay for a patient to go to another collaboration site • Varying Insurance contracts

9. OHSU-Legacy Cancer CollaborationAdvantages • Patients can receive quality cancer care at site convenient for them • Organizations use collaborative process to decide on New Technology – reducing duplication and cost • Providers design quality metrics and dashboards across sites - compared on a regular basis • Providers and staff can be shared across sites when needed • Working toward utilizing proven treatment pathways across the community platform

10. OHSU-Legacy Cancer CollaborationResearch • One of the original drivers of collaborative • Legacy had large number of patients with various cancer types • Community providers wanted to participate in research at their site • Both organizations had various memberships in Cooperative groups • Hurdles to overcome • Each organization had separate IRBs • Each organization needed “credit” for enrollment to maintain accreditation • Organizational control, Sorting out the finances

11. OHSU-Legacy Cancer CollaborationResearch – Successes • Developed a Memorandum of Understanding between 2 organizations defining guidelines and responsibilities for each • More effective collaborations between research coordinators of each org • Increased accrual for both organizations • Still sorting out research aspects around genetic typing of tumor tissue

12. OHSU-Legacy Cancer CollaborationCurrent Status • Continue to see expansion of infusion volume • Gradual shift in referral pattern from For profit provider network to collaborative • Building of trust between providers from the 2 organizations • Interest from other organizations about potential inclusion in the collaboration • How do you include new members • Financially successful for both organizations

13. Intermountain HealthcareCase Study Presented by:Dr. William Sause Intermountain Healthcare William.sause@gmail.org801-507-3838 11

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16. IHC Market Share 1999Cancer Services • UCR Inpatient share averaged 39% 1995 - 1999 • This is the same as overall average share for all services • IHC Market share for 1999 by type: Cancer Type IHC UofU Others Breast 58% 20% 22% Prostate 45% 19% 36% Lung 49% 29% 22% Melanoma 34% 18% 48% Rectum 54% 19% 27% 14

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20. Challenges Monopoly creates some degree of physician alignment Monopoly delays innovative strategies to create physician and institutional alignment Geographic barriers make sub specialization a challenge Impossible to address all care processes 18

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22. Quality Improvement Hierarchy of Challenges Compliance Study & Operational Goal Adherence to NCCN Guidelines New Clinical Science Evidence Conflict of Incentive 20

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24. Quality Improvement and ResearchTumor-Specific Projects • Melanoma • Melanoma Database • Ear Melanoma Study • Lung Cancer • Pre-Operative Imaging • GYN Cancers • Endometrial Cancer Study • Ovarian Cancer Study • Endometrial Familiality Study • PAP & HPV Testing • Endometrial Lynch Syndrome • Stage III Radiation • Myometrium Invasion • Urologic Cancers • Prostate Quality of Life Study • Radiation Treatment Templates • Renal Cancer Database • Finasteride • Familial Polyp • Prostatectomy Length of Stay (LOS) • Prostatectomy Variable Cost Evaluation • Physician Report Card • PSA Recurrence • Prostatectomy Margin Status • Other • Multi-clinic Downstream Revenue • Neuro-Oncology Database 22

25. Quality Improvement and Research • Breast Cancer • ER/PR Specimen Handling • Breast Reconstruction • Oncotype DX Testing • MRI Utilization in Breast Cancer Patients • Short-Term Imaging Follow-Up • Sentinel Lymph Node • Tissue Procurement • Time to Biopsy • Mammography Callback Rate • Early Stage Adjuvant Radiation Therapy • Node Dissection Rate for DCIS • DCIS at Diagnosis • Axillary Dissection Following Positive Sentinel Node Biopsy • Early Stage at Diagnosis • Neoadjuvant Chemotherapy • ER/PR Hormone Therapy • Micro metastasis • Hypo-fractionation • Breast Screening Cost • BIRADS 3 • Colorectal Cancer • Stage III Chemotherapy • Rectal Cancer – Endoscopic Ultrasound • Colon Familial Polyp (HICCP-UPDB) • Metastatic Colon Cancer Tissue • Colon 12 Node Retrieval • HPNCC Genetics Study • Pancreaticoduodenectomy Study 23

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31. STUDY Patients are tracked using mammography tracking software that has been implemented and standardized across all facilities 1,454 patients were identified as having a lumpectomy and radiation between 2003-2007. Of these patients, 1,386 underwent short interval mammography Patients were identified through Intermountain Healthcare’s cancer registry, Intermountain’s electronic medical record (surgery and radiation data), and mammography. 29

32. Conclusion • Short term mammography may provide a mammographer baseline anatomic information • Short term mammography following modern breast conservation has very low yield for new ipsilateral invasive breast cancer • Eliminating short term mammography would result in a minimum direct cost savings of approximately $1,160,000 for this patient cohort over the study period • This analysis represents a worthwhile demonstration of comparative effectiveness research (CER) and has potential to be expanded to other treatment areas 30

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35. 2013 Oncology Board Goal Active Care/End of Life Care Transition Increase the percentage of newly diagnosed cancer patients with stage II or higher disease who have documented evidence (e.g., Advance Directive (AD), Physician Orders for Life Sustaining Treatment (POLST) Form, or Advance Illness Discussion (AID) Note) indicating that they have discussed the seriousness of their illness and possible need for End of Life (EOL) care. 33

36. Average Charge 2012 Lumpectomy/Radiation $16501 Mastectomy/Reconstruction $40057 34

37. Challenges • Cultural Process • Misaligned Incentives between providers/payers • Who benefits from the savings? • Overhead costs for quality improvement infrastructure • Outpatient measurements are lacking • No guarantee that quality improvement reduces costs • Process Cost improvement may be minimal relative to optimal utilization(Rationing) • Process savings overshadowed by technological and pharmaceutical costs? • Does new technology and pharmacy cost make adaptation of this process imperative? 35

38. Cancer Program Development Representative Patent Litigation Matters by Jurisdiction Disparate system Independent budgets Individual physicians or employed physicians are RVU rewarded Attempt to unite around care processes and quality Integration of value based care nascent. Substantial challenges with imperfect implementation 36

39. Building a Regional Cancer Care Collaborative: Structural Options Presented by: Michael L. BlauFoley & Lardner LLPmblau@foley.com617-342-4040

40. Select Structural Options for Regional Cancer Care Collaborative • Affiliation Agreement/Regional Cancer Council • Contractual or Equity JV/Financial Consolidation • Hospital Within A Hospital • RT Joint Venture Technical Service Company • New JV Cancer Facility • Align Oncologists Through Employment/PSA or other alignment strategies

41. Affiliation Agreement • Representation of stakeholders • Coordinated planning and services Regional Cancer Council Notes • Oncology services provided under separate licenses of affiliated hospitals and medical groups, and billed separately: no economic alignment • Oncology program may be co-branded with a common name • Council establishes clinical and operational standards for co-branded oncology program • No license/CoN process implicated • Antitrust pricing, market allocation and data exchange constraints Hospital Affiliate(s) AMC/Community Hospital Affiliation Agreement Oncology Groups

42. Equity JV/Financial Consolidation Pooled Oncology P&Ls Notes • Financial consolidation and equity in ManageCo limited to affiliated Hospitals (not oncologists) • Oncology services provided under separate licenses and billed under provider numbers of affiliated Hospitals and oncology groups • Equity in ManageCo based on relative value of contributions • Certain centralized management services for oncology service lines • ManageCoco-manages oncology program (through ManageCo governance process) • Oncology program may be co-branded with common name • No license/CoN process implicated (unless major equipment is transferred to ManageCo) • May require HSR filing if more than $73 million of value contributed • Hospitals contribute oncology staff/certain equipment • Financially consolidate oncology operations Strategic Affiliation Agreement AMC/ Community Hospital Hospital Affiliate(s) Ownership Management Services ManageCo

43. Hospital Within A Hospital Notes • License and CoN (in CoN states) required for hospital within hospital • Tenant hospital has to meet physical separation standards (separate entrance, waiting area, staff, etc.) • Oncology services provided under license and billed under provider numbers of tenant hospital • Tenant pays lessor Hospital fair market value for space and other support services provided by Hospital Affiliate • Oncology program may be co-branded AMC/ Community Hospital Space lease/support services Hospital Affiliate Hospital Affiliate provides space, and possibly equipment and/or staff Ownership/License Hospital within Hospital Affiliate space Hospital Within Hospital Affiliate

44. RT JV Technical Service Company Payors AMC/ Community Hospital Notes • Model cannot be used for medical oncology services • New sites or upgrade vs. just existing sites/services • Stark: LLC cannot “perform” the RT services (e.g., oncology group needs to employ RTs); exclusive use of space (problematic for inpatient services, which are provided under arrangements?) • Constraints on non-profit/for-profit JVs; Rev. Proc. 97-13 constraints • Technical Services Agreement payment must be FMV, • Regulatory approval for transfer of ownership of Lin Accs? Hospital Affiliate(s) Oncology Group(s) Physician office rates $ Oncology Group • License space • RT equipment • Leasehold improvements • Non-clinical staff Technical ManagementLLC Technical ServiceAgreement ROs/RTs

45. New JV Cancer Facility Hospital Affiliate(s) AMC/ Community Hospital Notes • Cannot be Medicare provider-based (HOPD) unless on campus of one of the JV hospitals • New license and CoN (in CoN states) needed • License as new hospital or free-standing clinic • Could be physician office model (in certain states) or IDTF/Radiation Therapy Center paid at physician office rates • Oncology services provided under license and billed under provider numbers of new free-standing Cancer Facility • Owners share profit/losses from operations • Can be co-branded Ownership Hospital contribute oncology staff/certain equipment Cancer Facility Separately licensed oncology service

46. Aligning Oncologists: Hospital Provider-Based Conversion Notes • FMV for assets and Onc Group retains cash and A/R • PSA on fair market wRVU basis (with performance incentives) • MSA on a fixed fee or budgeted cost plus fair market mark-up basis • Billing services at fair market percentage of collections or fixed fee per claim Payors Affiliated Hospital Hospital provides: • License • Provider-based status • Space/equipment • Nurses/techs (off-campus) Professional Services Agreement Asset sale Group provides: • Physicians/NPs/PAs • Non-clinical staff • Nurses/techs (on-campus) • Management services? $/wRVU Oncology Sites/Service Line Oncology Group $ MSA/Billing Agreement

47. QUESTIONS?