Innovative Cancer Care Initiative #3 Transitioning to Risk - Episodes & Bundles

2. Innovative Cancer Care Initiative #3 Transitioning to Risk - Episodes & Bundles

3. Panelists • John Hennessy, M.B.A. Vice President Operations, Sarah Cannon Cancer Care • Steven Peskin, M.D., M.B.A, F.A.C.P. Senior Medical Director, Horizon Blue Cross Clinical Innovation • Mark L. Sobczak, M.D. Senior Vice President and Chief Network Officer, Fox Chase Cancer Center

4. Innovative Cancer Care Initiative #3 Transitioning to Risk - Episodes & Bundles Mark L. Sobczak, M.D.

5. Why Enter the Bundled Payment Plan Market At All? Standardized Bundles by Service Line • Cardiac Services • Acute myocardial infarction • AICD generator or lead • Atherosclerosis • CABG • Cardiac arrhythmia • Cardiac defibrillator • Cardiac valve • Chest pain • Congestive heart failure • Pacemaker Pacemaker device replacement or revision • Percutaneous coronary intervention • Syncope & collapse • General Surgery • Major bowel • Neurology • Stroke • Transient ischemia • General Medicine • Cellulitis • COPD, bronchitis/asthma Orthopedics Double joint replacement of the lower extremity Fractures femur and hip/pelvis Hip & femur procedures except major joint Lower extremity and humerus procedure except hip, foot, femur Major joint replacement of the lower extremity Major joint, upper extremity Medical non-infectious orthopedic Other knee procedures Removal of orthopedic devices Revision of the hip or knee Vascular Services Amputation Major cardiovascular procedure Medical peripheral vascular disorders Other vascular surgery Hematology Red blood cell disorders Diabetes Esophagitis, gastroenteritis, and other digestive disorders Gastrointestinal hemorrhage GI obstruction Nutritional and metabolic disorders Other respiratory Renal failure Sepsis Simple pneumonia and respiratory infections Urinary tract infection Spine Back & neck except spinal fusion Cervical spinal fusion Combined anterior posterior spinal fusion Complex non-cervical spinal fusion Spinal fusion (non-cervical) None are Oncologic in Nature! Source: Center for Medicare and Medicaid Innovation; Advisory Board Company, Financial Leadership Council interviews and analysis.

6. Why Take the Lead in Bundled Payment Projects? • Pilot Participation Offers Multiple Advantages • Preparation for Reporting, Risk-Based Payments Pilot participants benefit from familiarity with program, performance enhancements, when initiatives are expanded beyond pilot phase • Influence Metrics, Incentive Design • Provides opportunity to shape the development of quality measures and payment models • Performance Transparency • Pilot participants often gain access to payer data and/or cohort benchmarks; useful for pinpointing improvement opportunities • Performance Improvement • Helps focus larger team on cost and quality goals, accelerate performance improvement efforts Source: Oncology Roundtable interviews and analysis.

7. The Fox Chase Cancer Center & Partners Network • Fox Chase is designated a Comprehensive Cancer Center by the NCI • Partners Network established 27 years ago as the nations first Cancer Network • 11 unique hospitals or hospital systems with care delivered at 20+ sites • FCCC physicians practice at some sites

8. Bundles in Radiation and Surgery May Be Easier to Launch Radiation Therapy Bundle • •Three-year contract started August 2012 • •21st Century Oncology provides radiation therapy for 13 cancer diagnoses in exchange for bundled payment • •Diagnoses include breast, lung, prostate, gastrointestinal, and gynecological cancers • •Payment includes consultation, imaging, dosimetry, treatment delivery, and follow-up for 90 days • •Contract covers patients treated at any of 21st Century’s more than 250 facilities Radical Prostatectomy Bundle •Contract started April 2011 •Mobile Surgery International is an independent surgical group based in Miami, FL; performs surgeries at Jackson North Medical Center •Bundle covers laparoscopic radical prostatectomy •Goal is to improve care coordination, reduce complications, and simplify billing •Bundle was initially developed to provide price transparency to patients from overseas Source: Tocknell MD, “Humana, FL Physicians Group Bundle Radiation Services,” HealthLeaders Media, August 15, 2012, available at: http://www.healthleadersmedia.com/content/FIN-283436/Humana-FL-Physicians-Group-Bundle-Radiation-Services, accessed August 30, 2012; Oncology

9. FCCC is a Regional Powerhouse in Urologic Care

10. Renal Cell Carcinoma as a Potential Bundle

11. Why Localized Kidney Cancer? • Management options are predominantly surgical • Managed exclusively by one specialty • Discrete outcomes related to hospital episode • Few disease specific events during global period Potential Obstacles • Variation in type of procedures performed at the hospital and provider level

12. Established Approaches to Care

13. Procedure vs. Volume Statistics • Rate of partial nephrectomy increases with procedural volume • Hospital volume/experience plays an role in the adoption of new surgical techniques • FCCC surgeons perform >200 renal procedures/yr • From: Smaldone & Uzzo: AUA 2011

14. Building An Episodic (Bundled) Payment • Maximize quality • Reduce variation • Minimize over-utilization • Tools: • Accurate severity adjustment • Performance measurement • Costs (margin) • Measure process (provider, hospital, payer level) • Adherence to best practice guidelines • Services utilization • Measure outcomes • Traditionally cancer specific mortality and overall survival • Inpatient mortality • Complications requiring intervention • Hospital readmission rates

15. Defining the Episode of Care • PRE-OP • TESTING • Pre-operative imaging • Laboratory testing • HOSPITALIZATION • Surgery (Type) • Anesthesia • Nursing • OR time • Length of Stay • Services utilization • Post Discharge Care • INITIAL EVALUATION • Office evaluation • Decision for surgery • Staging imaging • Renal biopsy • GLOBAL PERIOD • Complications • Hospital readmissions • Services utilization • Office evaluation 90 Days

16. Final Steps • Method of identifying patients undergoing surgical management for localized kidney cancer • ICD9 code for RCC, ICD9 & CPT codes for surgery • Exclude patients with evidence of metastases or additional treatment • Determine the reliability of our cost data • Assessing the proportion of patients that receive care outside Fox Chase-TUHS during the global period • Management of complications and hospital readmissions • Testing the reliability of our models using an alternative dataset

17. Innovative Cancer Care Initiative #3 Transitioning to Risk - Episodes & Bundles Steven R. Peskin, M.D., MBA, FACP

18. InnovativeModelsof Care Oncology – Episodes of Care

19. The Triple Aim • Through collaboration, we are helping to create an effective, efficient and affordablehealth care system. • We are achieving better health and better care at lower costs. • Innovative programs: • Patient-Centered Medical Homes (PCMHs). • Accountable Care Organizations (ACOs). • Episodes of Care (EOC). 1 2 Reduce Per Capita Cost of Care Improve the Health of the Population Triple Aim Enhance the Patient Experience 3

20. Expansion of Horizon BCBSNJ’s Patient-Centered Programs January 2011 July 2012 July 2013 • 450 practice locations • More than 1,400 participating physicians • Benefiting over 320,000 Horizon BCBSNJ members

21. Five key elements to achieve sustainable results

22. Oncology Episodes of Care- We Are Working With The Episodes of Care team is collaborating with 2 entities this year to create custom oncology episodes of care. • Kidney Cancer Episode – aligning with Fox Chase Cancer Center- Temple Health- In progress • Breast Cancer Episode- aligning with New Jersey Society of Oncology Managers (NJSOM) 5 practices effective 10/1/13

23. Fox Chase Program Goal is to manage kidney cancer with surgery Fox Chase Episode of Care Program will focus on the Optum ETGs of 513 and 515. This includes active management with surgery and without active management with surgery. The diagnosis codes of 189 and 209.24 are also included. They represent malignant neoplasm of the genitourinary system. Program Duration: 30 Days Pre-Surgery and 90 Days Post Surgery Program Surgeries: • Minimally invasive - partial • Minimally invasive - radical • Open partial • Open radical Program Services: • Inpatient Days • Outpatient Visits • Professionals Services • Ancillary Services

24. NJSOM Program Goals The NJSOM Episode of Care Program will focus on patients diagnosed with breast cancer and receiving adjuvant breast cancer treatment to improve quality of care to patients, improve patient experience and reduce overall cost of care. Program Dimensions: Duration: • 84 days pre-trigger (1st Chemo treatment-96413) and dependent on protocol: 16, 20 or 24 weeks. • Herceptin would be measured by end code J9171 or J9265 billed with the last 96413 code billed. Inclusion Criteria: • Members with newly diagnosed breast cancer (billed with new patient code(s) 99201-99205) as of 4/1/2011. • Member with newly diagnosed breast cancer with HER2 positive diagnosis as of 4/1/2011.

25. Proposed Oncology Quality Metrics • Standards For All Episodes of Care: • Pre and Post-Op Procedure Patient Education • Care Coordination and Shared Decision Making • Plan All Cause Re-admission: 30 day readmission rate Recommendations from NJSOM and Fox Chase on Additional Quality Measures for Breast and Kidney Cancer Respectively are in discussion. | 25

26. RCCA and COTA Program Goals Regional Cancer Care Associates (RCCA), a participating oncology practice and Cancer Outcome Tracking and Analysis (COTA), a computer software used to track patient activity and advise re treatment protocols in real time, partnered with Horizon BCBSNJ to submit to the Centers for Medicare & Medicaid Services a grant application for an oncology performance based program. • Grant Submission Date: August 15, 2013 • Grant Title: Outcomes and Value–based Cancer Care • Program Goals: To provide an integrated technology and reimbursement program to provide real time advisement to physicians to optimize outcomes in conjunction with evidence based guidelines, which ultimately will result in reduction of unnecessary treatment and cost