navigating the oncology care maze
TRANSCRIPT
Navigating The Oncology Care Maze:
Evidence Based Medicine As A Pathway For
Payers, Providers & Patients
Dr. Mickey Goldsmith
Chief Medical Officer, New Century Infusion Solutions
The Center For Business Intelligence3rd Annual Effective Oncology Benefit Management Conference
October 6, 2008
Why I’m Facilitating This Workshop
I have a broad perspective on oncology care:
• Practicing community oncologist 25+ years
• Managed care executive & medical group CEO
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• Managed care executive & medical group CEO
– City of Hope Oncology Network
• Single specialty IPA with 800,000 lives
• Speaker on oncology managed care issues
Why I’m Facilitating This Workshop
– Currently Medical Director of New Century Infusion Solutions (NCIS)
– NCIS is the first Integrated Single Specialty Provider (ISSP) in oncology
– A new type of health care payer
» Takes risk
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» Takes risk
» Capitated (professional, drugs & radiation therapy)
» “Payer for the payers”
– Share NCIS experience• Policies developed from EBM can cost effectively deliver
oncology care• Specific takeaway ideas other payers can use
Workshop Agenda
• The Oncology Landscape
– Current perspectives
– A new perspective
• Evidence Based Medicine
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• Evidence Based Medicine
– What it is, & what it is not
• EBM in Community Oncology Care
– 5 specific examples
• Case Study Exercise
The Oncology Care LandscapeCurrent Perspective
Payers
• Challenges
– Supporting Cost-effective Cancer Care– Supporting Cost-effective Cancer Care
– Controlling Rapidly Escalating Rx Costs
– Managing Off-label Rx Use
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The Oncology Care LandscapeCurrent Perspective
Providers
• Challenges
– Incorporating Evolving Standards of Care Into – Incorporating Evolving Standards of Care Into
Practice
– Receiving Adequate Reimbursement
– Utilizing New Agents and Therapies
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The Oncology Care LandscapeCurrent Perspective
Patients
• Challenges
– Working with payers and providers to access – Working with payers and providers to access
appropriate care in a timely manner
– Receiving high quality cancer care
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The Oncology Care LandscapeCurrent Perspective
Patient Need for Quality Care
New
Research
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Delivery of Cost EffectiveOncology Care
Rx Costs
Off-Label
Rx
New
Agents
Research
ProviderFees
Changing the Oncology Care
LandscapeThere’s a need for a new type of oncology care system to handle the financial and clinical challenges of care from all perspectives:
•Financial challenges
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•Financial challenges– Some heath care plans can’t manage risk or are unwilling to
bear all of the risk
– ASP +6 reimbursement poses serious practice sustainability challenges for many providers
– Acceptance by provider of drug replacement & “brown bag” issues
Changing the Oncology Care
LandscapeThere’s a need for a new type of oncology care system to handle the financial and clinical challenges of care from all perspectives (continued):
•Clinical
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•Clinical– Many community oncologists have difficulty keeping up on
alternative treatments and advances in the standard of care published in the literature
– Payers need to know which treatments are appropriate
The New Oncology Care Landscape
Leveraging the power of EBM can change the landscape to:
New Agents
Provider
Payer
Professional Fees
Prior Authorization
Provider Network
InformationTechnology
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Delivery of Cost Effective Oncology Care
Patient-Centered EBM Care & Guaranteed Payer Savings
Off-Label Rx
Agents
Provider Fees
Patient
Preferred Drug List
Fees
Site of Rx Administration
The New Oncology Care Landscape
• New Century Infusion Solutions
– Overcomes key payer challenges• Cost escalation
• Over & under utilization
– Solves key provider challenges• Responsive prior authorization policies and processes
• Appropriate and timely reimbursement
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The New Oncology Care Landscape
• New Century Infusion Solutions resolves the financial and clinical challenges of cancer care
– Financial• Assumes the risk
• Acts as the “payer for the payer”
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• Acts as the “payer for the payer”
• Facilitates delivery of appropriate care by eliminating reimbursement misalignment between payers, providers and pharmacy
– Clinical• Uses EBM as a patient-centric pathway to deliver full spectrum
oncology care
• EBM optimizes curative, adjuvant and palliative therapies
Evidence Based Medicine
The fact that an opinion has been
widely held is no evidence
whatever that it is not utterly
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whatever that it is not utterly
absurd…
-Bertrand Russell, philosopher, historian, logician
Evidence Based Medicine
Evidence-based medicine is the
conscientious, explicit and judicious
use of current best evidence in making
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use of current best evidence in making
decisions about the care of individual
patients.
- The Cochrane Collaboration
Evidence Based Medicine(EBM)
What it is
• Based on Research
• Dependent on quality of
evidence
What it is not
• Uniformly practiced by
clinicians
• Based on a consensus
definition of evidence
• Rapidly evolving
• Outcomes oriented
• Guidelines based
• Decision oriented
definition of
“effectiveness”
• Fully integrated into
oncology care delivery
systems
• Directly tied to payer
return on investment
EBM in Community Oncology Care
• Using EBM to advance the standard of care in a community oncology setting blends:
ASCOResearch Payer
Dx & Rx Patient
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CMSDeterminations
Dx & Rx
Authorization
Process
Patient Progress
Patient Therapy
Curative
Adjuvant
Palliative
NCCNEvidence driven,
consensus based
guidelines
EBM in Community Oncology Care
Leveraging the power of EBM1. Develop well defined policies based on recognized
protocols
2. Distinguish between accepted and acceptable treatment protocols
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treatment protocols
3. Integrate oncology specialists into the authorization process
4. Orient the Payer Rx authorization process to say “yes”
5. Embrace advance care planning as an integral part of the spectrum of patient care
Leveraging the power of EBM
1. Develop well defined policies based on recognized protocols
Situation
• Not all cancers have standard protocols
• 40% of Rx is off-label use
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• 40% of Rx is off-label use
Opportunity
• Develop policies based on peer-reviewed literature, for example:
– Prophylaxis of CINV based on emetogenic potential of chemotherapy agents
– Erythropoiesis-Stimulating Agents (ESA)
Leveraging the power of EBM
2. Distinguish between accepted and acceptabletreatment protocols
Situation
• Erythropoiesis-Stimulating Agents (ESA)
• Some health plans only authorize FDA approved package insert
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• Some health plans only authorize FDA approved package insert dosing schedules
Opportunity
• There are many acceptable alternative regimens
• Facilitate provider preference
Leveraging the power of EBM
3. Integrate oncology specialists into the authorization process
Situation• 40% of Rx utilization in community oncology is off-label use• EBM guidelines and standards of care are rapidly evolving
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• EBM guidelines and standards of care are rapidly evolving• Most community oncologists don’t have the opportunity to speak
directly with a peer when navigating the payer’s authorization process
Opportunity• Have oncologists with oncology practice experience and
knowledge of cutting edge EBM involved in the first line authorization review to accelerate P.A. resolution and patient treatment
Leveraging the power of EBM
1. Oncologist as initial reviewer– Compliance
• Health plan• National oncology guidelines
– Regimen• Therapy appropriate to disease staging• Treatment length
4 Key Steps to integrating oncology specialists into the authorization
process:
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• Treatment length
2. Oncologist & oncology pharmacist collaboration– Preferred drug list
– Dosage appropriate to patient height and weight
– Dose optimization to prevent wastage and to promote cost effectiveness
3. Inclusion of a 2nd community oncologist as a 2nd level review prior to any recommendation for an authorization denial
4. 3rd level academically based reviewer is available at health plan’s request
Leveraging the power of EBM
4. Orient the Payer Rx authorization process to say “yes” to appropriate care
Situation
• Most Rx authorization gatekeeper processes are designed to save money by saying “no”
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Opportunity
• Standards of care vary by practice– Authorization process facilitates advancing SOC
• “Please educate me”
• Leverage technology to provide empowering information– Internet based systems
– Authorization processing information • Diagnosis & staging• Regimen info & patient history• J-Codes• EBM Literature references
Leveraging the power of EBM
Benefits From Orienting the Payer Rx
Authorization Process to Say “Yes” to
Appropriate Care
• Appropriate Patient Care
– NCIS experience: 1 denial in 2 years
• Wrong drug for stage of disease
• Denial upheld by health plan
Leveraging the power of EBM
5. Embrace advance care planning as an integral part of
the spectrum of patient care
Situation
• End of life care is one of the most costly stages of oncology care
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• End of life care is one of the most costly stages of oncology care
Opportunity
• Do the right thing
• Incorporate EBM end of life guidelines into oncology practice
• Reimburse providers for appropriate:
– Palliative Rx
– Encounters: office/hospice/home
Thank You
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Thank You
About The Facilitator
• Dr. Myron “Mickey” Goldsmith is the Chief Medical Officer for New Century Infusion Solutions (NCIS). NCIS is the first and only Integrated Single Specialty Provider delivering full-spectrum solutions in the oncology care market.
• A community based medical oncologist with over 25 years experience, Dr. Goldsmith, has:
– Served as Executive Director of Development for the City of Hope
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– Served as Executive Director of Development for the City of Hope Oncology Network
– Consulted to many health plan, disease management and pharmaceutical clients
– Authored many articles concerning clinical research in hematology or oncology and several publications on issues of oncology managed care.
• Dr. Goldsmith was a graduate of Temple University and Temple Medical School and performed his postgraduate training at the Graduate Hospital of the University of Pennsylvania. He can be reached at [email protected]