The Institute for Value-Based Medicine®, an initiative of The American Journal of Managed Care®, traveled to Teaneck, New Jersey, for presentations in partnership with Regional Cancer Care Associates.
Practices taking part in the Oncology Care Model (OCM) will soon reach a point when 2-sided risk will be forced upon them,1 and innovation will be key to survival, according to a group of stakeholders who recently discussed their successes and challenges.
Innovation will hold the key to improving quality metrics, patient care, and the bottom line, healthcare executives said at a July 18, 2019, meeting of the Institute for Value Based Medicine®, a special project of The American Journal of Managed Care®. Iuliana Shapira, MD, chief medical officer of Regional Cancer Care Associates (RCCA), served as moderator and host for the meeting held in Teaneck, New Jersey, where panelists shared how they are transforming piles of data into action items that can improve health and quality of life. Driving this transformation are new analytic tools and artificial intelligence (AI).
Barry Russo, chief executive officer of The Center for Cancer and Blood Disorders (CCBD), based in Fort Worth, Texas, described the journey the oncology practice has been on since it began working with Jvion, a prescriptive analytics company, to help it better manage the 6000 patients it sees a year.
Russo said there are 5 areas where AI can be particularly valuable:
• Coping with a data explosion, in which medical data are projected to double every 73 days by 2020.2
• Addressing physician shortages and rising burnout
• Taming an increased number of medical images
• Managing vulnerable populations
• Dealing with increased costs and complexity in the life sciences CCBD went through several phases as the practice worked to figure out how to best use AI, Russo said.
At the point of care, physicians are using it to riskstratify patients. “When I went through the litany of how many value-based arrangements we have, that equates to about 1000 to 1100 patients that we should be managing at any given time, meaning that they need case management oversight,” said Russo.
However, he noted that CCBD “can’t hire enough case managers to focus on all of the bodies we’re bringing into a value-based arrangement. It’s not possible, financially or even or from a people standpoint.”
In trying to determine which patients needed active management, the practice started with all patients who were in stage IV, which ended up being the incorrect move, he said. That group did not have higher costs than others. Then the practice looked at all the patients who had cancer of the lung, head and neck tumors, and pancreatic cancer, as well as those who were stage III and beyond. That group, too, was not focused enough.
CCBD realized that by participating in the OCM, they had 6 years’ worth of claims data, because practices in the OCM are responsible for the total costs of care, not just oncology costs.3 It turned out their most costly patients are cancer survivors—those who are 5 to 10 years post treatment who are still being monitored.
“They are kind of healthy,” said Russo, “except they fall. They have joint replacements. They have MIs [myocardial infarctions], and when we looked at our data, we’re like, wait a minute. We have people who are just on AI; unfortunately, they’re attributed to us because we see them for E&M [evaluation and
management] visits more often than anybody else does. And they’re costing us a fortune.”
THE LESSONS FROM JVION
Jvion ingested all of CCBD’s clinical data and mixed it with socioeconomic and other data to create a proprietary system of 7 vectors. The organization found that socioeconomic data is a huge flag that signals risk for more complex care in a patient population. Risk factors include having lower education levels, lower income, living alone, and residential instability, or not owning a home.
Data companies like Jvion buy zip code—level data from government agencies, whether it is the Census Bureau or the Department of Housing and Urban Development, or from technology companies like Amazon, which signals a person’s level of technology literacy.
“It isn’t just clinical complexity, it’s socioeconomic complexity and how you link the 2 of them together,” Russo said.
Jvion sorts patients into 7 vectors at risk for the following:
• 30-day mortality
• 30-day pain management
• 6-month depression risk
• 6-month risk for deterioration
• 30-day avoidable admission
• 30-day emergency department visit
• 90-day readmission
It also takes in historical claims data from every other provider.
CCBD soon started sending reports back to physicians based on their individual data. Some resisted the information, but others were open to the idea, Russo said. The reports offered value because they flagged which patients would never have been identified as being at risk of morbidity or mortality.
CCBD is also validating the 7 vectors internally, with varying levels of progress. For instance, the 30-day mortality risk is 35% validated, while the risk of a patient becoming an inpatient admission within 30 days is 100% validated.
Case managers can now focus on the people at the highest risk, Russo said. CCBD is still optimizing how Jvion can recommend interventions, but one thing it can do is automatically refer patients for pain management. In addition, the psychology team is proactively calling patients flagged by the system, which the practice now calls “the brain.”
Jvion also is using the system to identify patients who show up in multiple vectors, as Russo said, because “people that are at risk for more than 3 [vectors], maybe that actually would be a better way to catch the patients.”
CCBD is also identifying their own group of what Russo calls “socially challenged” patients so that social workers can make proactive calls to this group. The social workers make sure that applications for financial assistance are filed; Russo noted that the more people that file and are approved for help, the more the OCM score rises.
Another outcome: As a result of the ability to look more closely at data related to morbidity and mortality, referrals for pain management, palliative care, and hospice have all climbed.
In addition, CCBD is asking for Jvion to create a vector for inpatient fall risk; in the meantime, CCBD asks patients if they have had a fall in the past 30 days. Russo said they are “begging Jvion to move into the outpatient area, so that we can get those patients automatically referred to our pre-hab program.” This is because rehab costs are higher than those for inpatient admissions and are attributable to CCBD under the OCM.
Without AI, “there’s no way to manage these populations. We’ve got to have a better way,” said Russo.
The next steps for CCBD will be to use AI to go after issues related to electronic health records (EHRs) so that clinical, financial, molecular, pathways, costs of care, referral preferences, or requirements of accountable care organizations data are integrated and can be more than just a repository that cannot be acted upon.
The biggest issue, however, is putting all of the relevant information about a patient before the provider at the point of care, without the EHR rejecting requests and creating more work, Russo said. As an example, he pointed to UnitedHealthcare’s decision to only pay for the brand-name pegfilgrastim, Amgen’s Neulasta, and not a biosimilar as of July 1. Russo noted that Aetna uses Sandoz’s Zarxio, and other payers may insist on something else. As more oncology biosimilars enter the marketplace, this will only become more complicated for physicians as they try to enter orders, he said.
“We have to go back to the physician, start the order process again, and go back to the precert process again. We don’t have time for it. You can’t do it. Biosimilars are complicating the whole process of the point of care so much,” he said.
USING DATA TO ENGAGE WITH EMPLOYERS, DRIVE VOLUME
When the physicians at Michiana Hematology Oncology in South Bend, Indiana, decided to get ahead of what they saw as a dawning technological transformation in healthcare, they wanted to do so on their own. Kim Woofter, RN, who works at the practice, began using a local data analytics firm a few years ago to understand all of their disparate data sets so physicians could start acting on them.
Then South Bend awarded a $1 million grant to build their “data lake.” With that, Michiana spun that part off into a new company, the Advanced Center for Cancer Care (ACCC), which is now the data component of Michiana, said Woofter, who is now the executive vice president of strategic alliances and practice innovation at ACCC.
Michiana Hematology Oncology, a practice with 15 physicians, 9 locations, and about 4000 new patients a year, intended to use the data for its own internal purposes. But then a manufacturing firm with about 8500 employees called her and asked, “Hey, Kim, if you can look at your data, can you look at my spend data?
While employers across the country are struggling with healthcare costs, this company was also trying to retain a skilled workforce in an area where the unemployment rate was 1.2%; their goal was to lower their costs so that they could also drastically reduce the workers’ share.
The data lake now includes data sets from oncology, employers, orthopedics, surgery centers, and multispecialty groups. The most important thing, Woofter discovered, was being totally transparent in the cost of care; she said she was shocked by the variances in payments between what self-insured employers (even her own company) paid to the network and what the network paid providers. It gave her a chance to see “both sides of the coin,” she said.
To really make a difference with employers and demonstrate value, she recommends setting up a fee schedule that bills the contracted rate. In one case, she was able to show that for a single ill employee, the employer was charged $4400 for Neulasta even though the local hospital charged $19,519. Co-pays change patterns as well, Woofter said; for example, at an outpatient center, for infusion, the copay is zero, but at a hospital, it’s $500.
“Those HR directors truly believed in their very soul that they had no control at all over the cost of healthcare that they were paying,” Woofter said. “We all agree that quality is the No. 1 denominator, but we have to marry that up with costs if we’re going to be a good steward.”
Another step they took was to create an app that showed the doctors the cost of the treatments they were prescribing. They are also trying to create what she called “a meaningful fee schedule” that will be community wide. And employers are getting “trigger alerts” if certain high-cost patients are pushing them closer and closer to the stop-loss limit (the employees are not named).
Employers are also interested in looking at predictive analytics in order to keep more people healthy and working so that they don’t have to go through the recruitment process again.
“We believe that our strategy was to solve the problem of the employer, instead of going in to say, ‘Here’s how much I want from you today’,” Woofter said. “We took the strategy of, ‘I’m here to solve your problem. And I want to be your partner.’”
VALUE IN THE EYES OF A PROVIDER AND PAYER: HORIZON AND RCCA
Shapira, who became RCCA’s chief medical officer in March 2019,4 explained that RCCA is a large OCM practice that operates in Connecticut, Maryland, New Jersey, and Washington, DC.
Lani Alison, BSN, MS-HCQ, PCMH, CCE, RCCA’s vice president of clinical affairs, noted that the organization takes the OCM’s 6 practice redesign activities and applies them to all patients, regardless of payer. “The OCM actually set the standard for us because we believe that is the highest and toughest standard of care,” said Alison.
There are different definitions of quality and value, but she noted, “quality becomes very personal to people with cancer.”
“For us, we would like to deliver on patient value,” she said Similar to CCBD, RCCA uses a population health model and applies it to oncology to stratify patients, from low to high risk. Both Alison and Susan Porretta, RN, BS, FAHM, the director of partner transformation at Horizon Blue Cross Blue Shield of New Jersey, the state’s largest insurer with 3.8 million customers, both said they are trying to improve palliative care and how doctors discuss dying. They urge that these conversations not take place at the last minute, when it becomes more difficult.
RCCA began adding licensed clinical social workers 2 years ago, a move physicians initially resisted. But now they want more social workers, Alison said.
Horizon also began a pilot palliative care project a year ago and may expand it to pediatrics, Porretta said. “If you were a physician who graduated from medical school more than 10 years ago. you were not educated on advanced care planning,” she said.
During a panel discussion that followed the presentations, Terrill Jordan, JD, RCCA’s president and chief executive officer, asked Russo and Woofter if they have “been able to convince your physicians that the data or AI will actually reduce their workload so that they’re not working as hard, because it will inform their decision making—inform how they deal with patients?”
Woofter said her organization is starting out small and is not quite up to using AI yet. Her hope, she said, is that technology will advance to a point where she could say to a potential hire, “You don’t have to document. You just come here and be a great doctor.”
“Is it the reluctance to accept change? Or is it the fact that they feel that the pathway [imposes] onto their practice?” asked Shapira. “It’s the latter. It’s probably a little bit a little both,” said Russo. “Doctors are afraid it will create more work if they have to click through more screens or boxes.”
One audience member asked how the role of the caregiver is represented or changing in the OCM. Alison noted that one of her best friends died from stage IV glioblastoma, and the institution where her friend was treated took extremely good care of her friend’s surviving son. Discussing her father’s own, current cancer fight, she said, “Caregivers really are the hidden keys to getting to the patient.”
“They already see that they need to talk to me, because whenever the hard questions are being asked of my father, he looks at me.”
“You have to meet the caregiver at the first hello,” she tells her staff.References
1. Patel K, Patel M, Lavender T, et al. Two-sided risk in the oncology care model. Am J Manag Care. 2019;25(SP6):SP216-SP220.
2. Densen P. Challenges and opportunities in medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.
3. Oncology Care Model. CMS website. innovation.cms.gov/initiatives/oncology-care/. Updated July 11, 2019. Accessed July 30, 2019.
4. Hopeful news for cancer patients from Iuliana Shapira, MD, RCCA’s new chief medical officer [press release]. Hackensack, NJ: RCCA; March 23, 2019. regionalcancercare.org/news/iuliana-shapira-md-rccas-new-chief-medical-officer/. Accessed July 30, 2019.