+
© Oncology Management Services, 2015
+ Part I.
Oncology Patient-Centered
Medical Home Overview
+
What is OPCMH©?
• The Oncology Patient-Centered Medical Home is a
model of healthcare delivery that empowers the
physician-led care team and enables them to practice
to the best of their abilities.
• The goal of OPCMH is to standardize the science of
medicine, so that care teams can practice the art of
medicine—and thereby provide better healthcare to
our patients.
• The OPCMH model offers a significant value
proposition to a wide-range of healthcare constituents
and to society…
+
Value Proposition
OPCMH offers providers a model of care
Empowering them to thrive economically in a
value-based environment
Delivering consistently high-value healthcare
Enabled by high-value, low-cost technology
OPCMH offers payers and health systems
Innovative aligned payment methodology options
IT to catalyze value-based transformation
Implementation of model across a provider network
Delivery of a value proposition based on controlling
resource utilization and improving patient safety
and desired outcomes
+
Highlights of the Model

Reorganizes roles and responsibilities of the existing team

No need to recruit additional staff in most cases


May not require extended hours


OPCMH may require fewer staff members per physician
OPCMH engages patients to report symptoms early and often—
and it works
Streamlines administrative & technical barriers in the care
team work environment (authorization process, EMR
functionality, documentation burdens, transcriptions costs,
etc.)
+
Highlights of the Model
 Patient
and physician-centered
 High-value patient care cannot be consistently
delivered if the model of delivery does not seek
to optimize the physician and care team workenvironment
 Minimize clinically irrelevant physician activity
 Top
down value solutions (e.g. pathways
programs, EMRs) often do not understand the
physician and care-team work environment
+ Barriers to quality = Physician Time Stealers:
+ Barriers to Cost Control

Drivers of cost = unnecessary resource utilization (waste)

Waste is driven by failures in:

Delivery

Coordination

Over-utilization

Pricing

Administrative Burden

Fraud
Clinical Domain
Administrative Domain
+
OPCMH focuses first and foremost
on standardizing the care team
work environment.
Oncology PCMH Quality & Value Driver Diagram
Triple Aim
Primary Driver
Secondary Drivers
Patient-,Payer-,and
Provider-Centered
Care Team Environment
Delivery Standards
Outcomes
Services
Process of Care Standards,
Care Integration,
Evidence Base
Multi-disciplinary
Guideline
Concordance
Engagement & Orientation
Patient & Family
Experience of Care
Palliation
Symptom Management
Focus on Performance
Status (PS)
Patient Responsibilities
Practice Responsibilities
Goals, Insurance Issues
Patient Navigation
Multidisciplinary Input
Scheduling & Tracking
Execution of Care
Avoidable Resource
Utilization
Staging/Guideline Adherence
Standardized Processes/Data
Care Coordination
Communication
ER/Hospitalizations
Imaging & Lab
Symptom Management
Survivorship Care
Standardized
Primary PCMH
End of Life Care
Hospice Enrollment
Place at Time of Death
Resource Utilization
Total Cost Of Care
Medical, Surgical, Lab
Radiation, Imaging
On Demand Access/Visits
Performance data collection
Track success of Palliation
Survivorship Care
National Committee for
Quality Assurance
PCSP Recognition
PCOC standards
American College of
Physicians PCMH-N
Patient Advocacy Data
NCCS, CSC, ACS
American College of
Surgeons
Commission on Cancer
Data Collection NCDB
Treatment & PC Standards
NCCN
Treatment Guidelines
Survivorship Guidelines
ASCO
QOPI Standards
Survivorship Guidelines
Standardized Care Plans
Coordination Agreements
Institute of Medicine
Goals of Therapy
National Quality Forum
National Cancer Policy Forum
Documented
PS Driven Discussions
Shared Decision Making
Payer Based Episode and
“OMH” Programs
CMS & Commercial
Data Driven Improvement
©2014 Oncology Management Services, Ltd.
Oncology PCMH Quality & Value Driver Diagram
Triple Aim
Primary Driver
Secondary Drivers
Patient-,Payer-,and
Provider-Centered
Care Team Environment
Delivery Standards
Outcomes
Services
Process of Care Standards,
Care Integration,
Evidence Base
Multi-disciplinary
Guideline
Concordance
Engagement & Orientation
Patient & Family
Experience of Care
Palliation
Symptom Management
Focus on Performance
Status (PS)
Patient Responsibilities
Practice Responsibilities
Goals, Insurance Issues
Patient Navigation
Multidisciplinary Input
Scheduling & Tracking
Execution of Care
Avoidable Resource
Utilization
Staging/Guideline Adherence
Standardized Processes/Data
Care Coordination
Communication
ER/Hospitalizations
Imaging & Lab
Symptom Management
Survivorship Care
Standardized
Primary PCMH
End of Life Care
Hospice Enrollment
Place at Time of Death
Resource Utilization
Total Cost Of Care
Medical, Surgical, Lab
Radiation, Imaging
On Demand Access/Visits
Performance data collection
Track success of Palliation
Survivorship Care
National Committee for
Quality Assurance
PCSP Recognition
PCOC standards
American College of
Physicians PCMH-N
Patient Advocacy Data
NCCS, CSC, ACS
American College of
Surgeons
Commission on Cancer
Data Collection NCDB
Treatment & PC Standards
NCCN
Treatment Guidelines
Survivorship Guidelines
ASCO
QOPI Standards
Survivorship Guidelines
Standardized Care Plans
Coordination Agreements
Institute of Medicine
Goals of Therapy
National Quality Forum
National Cancer Policy Forum
Documented
PS Driven Discussions
Shared Decision Making
Payer Based Episode and
“OMH” Programs
CMS & Commercial
Data Driven Improvement
Oncology PCMH Quality & Value Driver Diagram
Triple Aim
Primary Driver
Secondary Drivers
Patient-,Payer-,and
Provider-Centered
Care Team Environment
Delivery Standards
Outcomes
Services
Process of Care Standards,
Care Integration,
Evidence Base
Multi-disciplinary
Guideline
Concordance
Engagement & Orientation
Patient & Family
Experience of Care
Palliation
Symptom Management
Focus on Performance
Status (PS)
Patient Responsibilities
Practice Responsibilities
Goals, Insurance Issues
Patient Navigation
Multidisciplinary Input
Scheduling & Tracking
Execution of Care
Avoidable Resource
Utilization
Staging/Guideline Adherence
Standardized Processes/Data
Care Coordination
Communication
ER/Hospitalizations
Imaging & Lab
Symptom Management
Survivorship Care
Standardized
Primary PCMH
End of Life Care
Hospice Enrollment
Place at Time of Death
Resource Utilization
Total Cost Of Care
Medical, Surgical, Lab
Radiation, Imaging
On Demand Access/Visits
Performance data collection
Track success of Palliation
Survivorship Care
National Committee for
Quality Assurance
PCSP Recognition
PCOC standards
American College of
Physicians PCMH-N
Patient Advocacy Data
NCCS, CSC, ACS
American College of
Surgeons
Commission on Cancer
Data Collection NCDB
Treatment & PC Standards
NCCN
Treatment Guidelines
Survivorship Guidelines
ASCO
QOPI Standards
Survivorship Guidelines
Standardized Care Plans
Coordination Agreements
Institute of Medicine
Goals of Therapy
National Quality Forum
National Cancer Policy Forum
Documented
PS Driven Discussions
Shared Decision Making
Payer Based Episode and
“OMH” Programs
CMS & Commercial
Data Driven Improvement
Oncology PCMH Quality & Value Driver Diagram
Triple Aim
Primary Driver
Secondary Drivers
Patient-,Payer-,and
Provider-Centered
Care Team Environment
Delivery Standards
Outcomes
Services
Process of Care Standards,
Care Integration,
Evidence Base
Multi-disciplinary
Guideline
Concordance
Engagement & Orientation
Patient & Family
Experience of Care
Palliation
Symptom Management
Focus on Performance
Status (PS)
Patient Responsibilities
Practice Responsibilities
Goals, Insurance Issues
Patient Navigation
Multidisciplinary Input
Scheduling & Tracking
Execution of Care
Avoidable Resource
Utilization
Staging/Guideline Adherence
Standardized Processes/Data
Care Coordination
Communication
ER/Hospitalizations
Imaging & Lab
Symptom Management
Survivorship Care
Standardized
Primary PCMH
End of Life Care
Hospice Enrollment
Place at Time of Death
Resource Utilization
Total Cost Of Care
Medical, Surgical, Lab
Radiation, Imaging
On Demand Access/Visits
Performance data collection
Track success of Palliation
Survivorship Care
National Committee for
Quality Assurance
PCSP Recognition
PCOC standards
American College of
Physicians PCMH-N
Patient Advocacy Data
NCCS, CSC, ACS
American College of
Surgeons
Commission on Cancer
Data Collection NCDB
Treatment & PC Standards
NCCN
Treatment Guidelines
Survivorship Guidelines
ASCO
QOPI Standards
Survivorship Guidelines
Standardized Care Plans
Coordination Agreements
Institute of Medicine
Goals of Therapy
National Quality Forum
National Cancer Policy Forum
Documented
PS Driven Discussions
Shared Decision Making
Payer Based Episode and
“OMH” Programs
CMS & Commercial
Data Driven Improvement
+
Part II: The Prototype OPCMH
Consultants in Medical Oncology &
Hematology (CMOH)
+
Increased Productivity &
Decreased Overhead:
2013: 8.8 physicians, 3 service locations
Support staff to fulltime physician ratio 5.6 (2007
baseline 8.3)
Business Enhancement:
Enhanced FFS, PMPM, shared savings,
precertification relief
Improved documentation, coding, coordination
Improved physician efficiency, productivity, QOL
New referral patterns
Development of Alternate Payment Models:
APM contracts (IBC, Keystone First)
Covering 48% of practice patient base
Performance benchmarked against the market
+
Projected % Reduction in Cancer Care Cost
1-3
4-6.3
0.6-1.1
0.1-.4
0.9-1.9
Chemotherapy pathways program
Inpatient hospitalizations (5-25% reduction)
ER evaluations (20-40%)
Diagnostics
End-of-life care coordination
Total 6.6 – 12.7 % reduction
Annual cancer “spend” $125B = $8-16B savings
Adapted from international consultants evaluation of OPCMHTM application to cancer
care
Traction
PCORI funded Oncology Project (SEPA)
NCQA, OMS, ASCO, RAND, NCCS, IBC
CMS Oncology Payment Reform TEP
MITRE, Brookings, RAND, CMS, CMMI
Oncology Bundled Payment Consortium
CAP, CMS, CMMI, multiple payers
ASCO Payment Reform Initiative
OMS CMOH Alternate Payment Methods SEPA
IBC, Keystone First, (48% of patients)
Outcome of Clinical Nurse Triage Phone Calls in 2013
n = 5106 clinical phone calls
Manage Symptom(s) at home
84.21%
Pt sent for
Referred to
Radiographic
Primary/Specialist
Study
5.35%
0.41%
Go to nearest ER
Office visit tomorrow
Chemo Suite Intervention 2.39%
3.47%
0.22%
Office visit today
3.96%
7.43% of patients were seen in the
office within 24 hours of call
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology &
% of Clinical Calls to Nurse Triage Line That Were Managed at Home
28,179 Symptom Related Calls from 2006-2013
86.00%
84.21%
84.00%
82.00%
81.21%
81.37%
2011
2012
80.00%
77.55%
78.00%
77.06%
76.17%
75.80%
76.00%
74.00%
73.92%
72.00%
70.00%
68.00%
2006
2007
2008
2009
2010
2013
% Calls Managed Symptom(s) at home
Not for redistribution.
© 2013 Oncology Management Services,
Consultants in Medical Oncology &
Average emergency room (ER) Evaluations per chemotherapy
patient per year (APCPPY)
for the CMOH patient population , 2004-2013.
3.000
ER Evaluations per chemotherapy patient per year
2.600
2.567
USON/Milliman: Approximately 2 emergency room visits per
chemotherapy patient per year
2.500
2.067
(14 million commercially insured; 104,473 cancer patients)
Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
2.000
1.604
1.500
1.273
1.119
0.910
1.000
0.818
0.703
0.550
0.500
0.000
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Year
Not for redistribution.
© 2013 Oncology Management
Services,
© 2014 Oncology
Management Services,
Consultants
in Medical&Oncology
& Hematology
Consultants in Medical
Oncology
Hematology
USON/Milliman: Approximately 1 hospital
admission per chemotherapy patient per
year (n=14 million commercially insured; 104,473 cancer
patients)
Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
Provider Ability & Accountability
Payment Reform for cancer care
Episode or
Budgeted
FFS
OPCMH
Pathways
Not for redistribution.
Payment
model
© 2013 Oncology Management Services,
Consultants in Medical Oncology &
Part III. Scaling the Model
Oncology Management Services
+
Oncology Management Services
Solutions
Tools
Practical Guide
Practice Assessment
& Gap Analysis
Symptom Management
Program (triage algorithms,
patient instructions)
Technology
Support
Iris
Webinars
Seminars
Practice Consulting
Network Management & Contracting
Payer & Policy Organization Consulting
+ Iris™: The OPCMH Enabling Technology
Point-of-care, physician-centric software that minimizes the barriers
physicians and care teams face in providing value-based healthcare. Iris
is the tool that enables successful OPCMH transformation.

Iris enhances the OPCMH model of care by guiding and facilitating
workflow, minimizing clinically irrelevant activities, while collecting and
reporting clinically actionable data in real-time at the point of care.

Iris compliments EMR functionality. EMRs commonly provide a
detailed roadmap of how to impede value-based healthcare delivery.
Iris minimizes each of these barriers and enables seamless
transformation.

+
Iris™
The Iris effect:
+
Iris
TM
The Barriers to Cost Control

IrisTM addresses these cost drivers:

Delivery

Coordination

Over-utilization

Pricing

Administrative Burden

Fraud
+
Iris Consumers
TM
Referring Physicians
Associated Treating
Physicians
Consulted Specialists
Patients
Nurse Manager
Triage Nurse
Billing staff
Patient Navigators
Emergency Department
Hospital Admission Team
Home Care Team
Hospice Team
Survivorship Care Team
Tumor Registry
State Department of
Health
Plan Medical Directors
Plan Auditors
+
An Enabling Ecosystem
External Apps (SMART-on-FHIR)
OMS APP
OMS APP
OMS APP
OMS APP
Iris™
EMR
EMR
EMR
EMR
EMR
+
Thank you!
Contact Information
John D. Sprandio
jsprandio@cmoh.org
Visit us at www.opcmh.com to register
for OMS’ Healthcare Delivery Seminar