P4 Pathways
Provider Education Forum
Putting Pathways into Practice
CANCER TREATMENT PATHWAYS
Provider Education Forum
Pathways Program
June 24, 2010
Time
Agenda Topic
7:00 p.m.
Welcome & introductions
7:10 p.m.
Program overview
8:15 p.m.
Q&A
8:30 p.m.
Adjournment
ONCOLOGY INCHES CLOSER TO
BEING PAYERS’ TOP TARGET
Why control Oncology Rx?
Within the next 12 months, our plan will do the following
regarding oncology management:
40%
35%
32%
30%
22%
20%
11%
10%
0%
Develop
internal
oncology
management
program
Partner with
oncology
management
vendor
Partner with
specialty
pharmacy
vendor
None of these
in the strategic
plan at this
time
What do you view as the most important way for your
plan to save money in oncology long term?
69%
70%
60%
50%
40%
30%
20%
10%
0%
18%
9%
2%
Reduce
chemotherapy
fee schedule
Maximize
referrals to
hospice
Prior
authorization of
chemotherapy
regimens
2%
Practice
guidelines
Brown bag
(drop ship drug
to patient to
take to doctor
for
administration)
Assume your carrier has partnered with a third party to
manage oncology costs. Which is most acceptable to you?
50%
42%
40%
40%
30%
20%
10%
10%
0%
6%
2%
Reduce fee
Provide a monthly Provide a monthly
Implement
Implement
schedule and
fee for
management fee,
pathways but pay
pathways but pay
include prior
chemotherapy
but send patients to
me more for
me a management
authorizations to
management ,but
a free standing
participation (ASP + fee rather than high
manage therapeutic
supply drug via
infusion suite
27%).
drug payments
choice, but do not
brown bagging
(ASP + 12% plus a
utilize pathways
cancer
(ASP + 12%, higher
management fee)
generics)
Changing the Paradigm
Fee
Schedule
Manipulators
Balanced
Approach
Pathways
Program
Why P4?
Decade of Oncology Advocacy
Commitment to Community Oncologists
Established Managed Care Initiatives
• Existing Contract
• Pending Contracts
Demonstrated Success
• Payer and Physician Satisfaction
• Enhancing Physician Income
Scalable Technology
Agnostic to EMR, Distributor and Class of Trade
BCBST Program
300 ~ Oncologists between community and academic
practices
• ASP + 27% versus ASP + 20% for most antineoplastic
and supportive care drugs
• Higher reimbursement for generics
• Medicaid effective June 30, 2010; Commercial
effective September 7, 2010
• Participation = Maintaining compliance in clinical
pathways for breast, colon, lung, ovarian and
supportive care. Year one compliance is 70% for
treatment and 80% for supportive care
Pathways Program Objective
To increase quality and cost effectiveness through
the implementation of standard, evidence-based,
oncology clinical pathways for breast, colon, lung,
and ovarian cancer and for supportive care.
These will be followed by prostate, multiple
myeloma, CLL, follicular lymphoma, mantle
cell, and large B cell lymphoma in year two.
Year three will include additional pathways and
diagnostic testing.
Goals of the Pathways
 Utilization of a consistent treatment regimen based upon a
balance between outcomes, toxicity, and cost.
 Treatment pathways will:
•
Be based upon the scientific and clinical literature
•
Provide a standard approach to the patient (reduce misuse,
hospitalizations)
•
Decrease variability of regimens utilized, including “off label” indications
•
Clearly define treatment endpoints and treatment milestones
 Treatment consistency resulting from treatment pathways will
lead to:
•
Optimal outcomes
•
Minimizing and better management of toxicities
•
Allowing for a greater predictability of treatment cost
Treatment Pathways Implementation
30 to 90 Days
Pathway
Development
Provider
Education
Network
Development
•Developed by a Regional Steering Committee using P4 pathways as a starting point
•Evidenced-based looking at efficacy, toxicity, and costs
•Pathways will be fully referenced with FN risk levels and Hesketh scores
•General membership has commentary period before going into effect
•Quarterly updates
•Utilizing mail, e-mail, provider meetings, web conferences, and site visits
•Dedicated provider web portal (includes program description, Pathways, fee schedules, Q&As,
eobONE information, fax form, contact us, registration page, recorded web conferences, and
compliance module
•Recruitment from BCBS Tennessee’s participating network panel
•Physicians register for the program by executing a Declaration of Participation and receive a
welcome packet that includes credentials to secure areas of the program’s web portal
•eobONE contracting, installation, and training
Roles and Responsibilities:
BCBST
No change
Maintain provider panel
Define Fee Structure
Determine Coverage
Utilization Management
• Prior Authorization
• Post Payment Reviews
Roles and Responsibilities:
Physicians
No Major Change
Provide Care to Patients
Determine appropriate choice for individual patient
Develop and Update Clinical Pathways through a
Steering Committee
Participation in the Pathways Program is optional
– Pathway Adoption
– eobONE Installation or the ability to provide ANSI 835 & 837 files
– Adequate Compliance – Pass or Fail
Roles and Responsibilities:
P4 Pathways
Contract with BCBST
Coordinate the Development of Regional Oncology
Clinical Pathways
Communications to Membership
– Clinical Pathways
– Pathway Updates and Revisions
– Fee Schedules
Compliance Measurement
Compliance Reporting
– Physician
– Practice
– BCBST
Pathway Development Process
Sample P4
Pathways
Presented to
Physician
Steering
Committee
Steering
Committee
Breaks into
Sub-Committee
groups for
Pathway
Development
Full Steering
Committee
Reviews and
Finalizes Draft
Set of
Pathways
Pathways
presented to
BCBST for
Review
Pathways
presented to
full membership
for commentary
Final Pathways
referenced and
formalized
The Golden Rules
• Choice of treatment should always be guided by Efficacy
if clinically relevant
• If Efficacy between therapeutic alternatives is equal then
Toxicity might drive choice
• When Efficacy and Toxicity are similar among regimens,
Economics should drive utilization
The Challenge is the Misalignment of Economic Drivers Of Stakeholders
The Most Important Rule
The treating physicians have ultimate
decision regarding treatment. At no time
should patients receive sub standard
therapy because of Pathways.
The Pathways Project recognizes that not
all patients can be cared for using a
limited set of pathways. Compliance is
set to allow individual treatment.
Pathways Guidance
Must be driven by data and best practice
• PRIMARY LITERATURE
• NATIONAL GUIDELINES
• NCCN
• Professional societies (ASCO, ASH, GOG, RTOG)
Exhaustive enough to cover 90% of the eligible patients
Plan designed to allow outliers
When Pathways Physician Steering Committee identifies
equivalent therapy, economics are considered
Clear mandate that physician has ultimate control of treatment
decision at point of care
Pathways Maintenance
Independent board will review and modify
Pathways quarterly or after sentinel work to
modify Pathways
Process is transparent
Members of Pathways Physician Steering
Committee will rotate with other members of
the regional oncology community as needed
Cost Matters
When data is equivocal then cost matters
• Lower practice expense / Higher ROI
• Lower out of pocket for patients
• Savings for plan = Lower Premium to Employers
How We Handle Clinical Trials
Clinical Trials are a key aspect of Oncology care
and are considered on pathway
Patients without standard options should be
considered first for trial before ineffective
therapy
Coverage of clinical trials challenging but
should consider usual cost of care including
standard drugs. Drugs outside of label should
be provided at no charge by drug company.
Compliance Determinations
BCBS Tennessee, eobONE and Fax Form
data run through compliance algorithm
Sample Chart Audits to validate data
Data sent to providers and posted on the
web portal
Physicians review scores and appeal
relevant adverse determinations
Final Compliance set at the practice level
on a quarterly basis
eobONE results in a higher level of cash
reimbursement & improved staff productivity
•Find EOBs in seconds
• Increases “first-time paid” claims
• Maximizes the “crossover” of your Medicare
claims
• Increases your recovery rate—find claims that
are paid a rate of “zero dollars”
• Increase your staff’s productivity immediately
• Decrease your denial rate/increase your
recovery rate
• Decrease your real days outstanding
• Available to BCBS Tennessee providers at
reduced price of $600/physician/year
www.eobone.com
eobONE Data Capture
 eobONE = EOB + Claim
 ICD-9 Codes (from claim)
 J-Codes (from claim)
 HCPCS Codes (from claim)
 Billing and Collection
data/behaviors




Drug regimens/treatment
patterns
Supportive care
Physician visits – office and
hospital
Payment – when, what,
how much, denials, delays
Extrapolation





Diagnosis
Regimen
Treatment Schedule
Dose delays/
reduction, reduced
cycles, patient breaks,
etc.
Longitudinal Capture
26
P4 Pathways Physician Portal
Treatment Compliance
Supportive Care Compliance
NonCompliance
Reconciliation
BCBST/P4 Pathways Case
Management Referral Process
Sample Pathways
Final Pathways To Be Published
Prior to the Program Effective Date
Breast Cancer Treatment Pathways
Adjuvant Breast
(Lower Risk) – Node Negative, Her2Neu Negative
• Clinical Trial
• Hormone Therapy
• Anti-estrogen
• Aromatase inhibitor
• Chemotherapy (cross-referenced with pertinent Hesketh (H)
score and febrile neutropenia (FN) risk level)
• AC - doxorubicin (Adriamycin®) and cyclophosphamide
(Cytoxan®): H5, FN 10%-16%
• CMF - cyclophosphamide (Cytoxan®), methotrexate, and
fluorouracil: H5, FN 10%-16%
• TC - docetaxel (Taxotere®) and cyclophosphamide (Cytoxan®):
H5, FN>17%
Wrap-Up/Questions
Adjournment