Cancer Care in an ACO Landscape presented by Kelly Blair at the FLAACOs 2014 Fall Conference

1. Cancer Care in an ACO
Landscape
Kelly Blair, COO, Oncology Resource Networks
September, 2014

2. Kelly Blair Bio
Managed care leader with 17 years
experience leading quality and affordability
programs across multiple complex medical
condition areas.
10 years with UnitedHealthcare
5 years with Optum
VP of Oncology Products at MedSolutions
Joined ORN in March 2014 as COO
Masters degree in health policy analysis
Member of the Women’s Business Leaders
Mentiuum Alumni

3. The Oncology Problem
Cancer costs are increasing with no demonstrated improvements in the quality of
patient care1.
SPEND TREND
1Institute of Medicine, Delivering High-Quality Cancer Care 2013

4. The Evolving Payer Landscape
• Market consolidation will continue
in the form of delivery system
integration.3
• Payers and providers are moving
toward value-based contracts.2
• The number of ACOs will continue
to grow.1
1Leavitt Partners, ACO Updates and Market Transition Webinar, September 2013
2 Gamble, M and Punke,H, 100 Accountable Care Organizations to Know, Beckers Hospital Review, August 14, 2013
3 Oliver Wyman, ACO Update: Accountable Care at a Tipping Point, April 2014

6. Oncology ‘Showdown’ Territories
• Tremendous growth
rates in cancer services
• Providers will compete
for volumes
• Risk of consolidation to
high cost providers
• Payers will seek relief…
Data powered by

7. Orlando Growth Projections
Specifics: Oncology Resource Networks Market Demand Forecast application (IoC v13.0) accessed on 08/23/14. Data are for 2013–2018. Cancer service
line. Sources: Impact of Change® v13.0; PharMetrics; CMS; Sg2 Analysis, 2014.
Data powered by

8. Broward Growth Projections
Specifics: Oncology Resource Networks Market Demand Forecast application (IoC v13.0) accessed on 08/23/14. Data are for 2013–2018. Cancer service
line. Sources: Impact of Change® v13.0; PharMetrics; CMS; Sg2 Analysis, 2014.
Data powered by

9. Tampa Growth Projections
Specifics: Oncology Resource Networks Market Demand Forecast application (IoC v13.0) accessed on 08/23/14. Data are for 2013–2018. Cancer service
line. Sources: Impact of Change® v13.0; PharMetrics; CMS; Sg2 Analysis, 2014.
Data powered by

10. Tampa Chemotherapy Forecast
 66% of chemotherapy services in Hillsborough County are provided by Moffitt.
 9% of medical oncologists deliver 50% of the chemotherapy in FL.
 7 of the top 10 volume chemotherapy oncologists are affiliated with Florida
Cancer Specialists.
• Tampa will see a 41% increase in demand for chemotherapy services,
more than double the Southern Region and National growth.
Data powered by
Oncology - Chemotherapy 31,275 0.00% 35,546 13.70% 38,358 22.60% 44,012 40.70% 32.00% 20.40% 17.00%
Central Florida US South US
2013 2016 2018 2023 2023 2024 2024
Procedure Volumes % Change Volumes % Change Volumes % Change Volumes % Change % Change % Change % Change

11. Tampa Radiation Therapy Forecast
• Tampa will see a substantial increase in demand for radiation therapy
services, particularly for SRS/SBRT and Proton Beam modalities.
 55% of radiation therapy services in Hillsborough County are provided by Moffitt.
 4 of top 10 volume radiation therapists are affiliated with 21st Century Oncology
Data powered by
Hillsborough County US National
2013 2016 2018 2023 2024
Procedure Group Volumes % Change Volumes % Change Volumes % Change Volumes % Change Volumes % Change
Oncology - Radiation Therapy Oncology - Radiation Therapy 2,418 0.00% 2,688 11.20% 2,871 18.80% 3,208 32.70% 1,201,827 -3.20%
Oncology - Radiation Therapy: 3D Conformal and other EBRT 24,266 0.00% 25,735 6.10% 26,588 9.60% 27,686 14.10% 3,750,424 -1.30%
Oncology - Radiation Therapy: HDR Brachytherapy 625 0.00% 697 11.60% 744 19.10% 856 37.00% 125,627 24.50%
Oncology - Radiation Therapy: IMRT 25,605 0.00% 28,881 12.80% 30,959 20.90% 34,482 34.70% 3,825,334 9.80%
Oncology - Radiation Therapy: LDR Brachytherapy 327 0.00% 370 13.10% 399 21.90% 464 41.70% 36,579 22.20%
Oncology - Radiation Therapy: Proton Beam Therapy 238 0.00% 340 42.60% 375 57.50% 419 75.70% 124,357 60.20%
Oncology - Radiation Therapy: SRS/SBRT 481 0.00% 606 25.90% 703 46.10% 952 97.90% 208,526 103.60%
Oncology - Radiation Therapy
Total 53,961 0.00% 59,317 9.90% 62,640 16.10% 68,067 26.10% 9,307,038 5.00%

12. The Oncology System of Care
CARE = Clinical Alignment and Resource Effectiveness; MDC = multidisciplinary care; Med Onc = medical oncology; mgmt = management; OP = outpatient;
PCP = primary care physician.

13. Consider the Site…
Chemotherapy by Site of Care2
Hospital OP Office All Other
New York, NY 84% 15% 1%
Syracuse, NY 29% 55% 16%
Buffalo, NY 96% 4% 0%
San Francisco, CA 59% 37% 4%
Los Angeles, CA 30% 70% 0%
San Diego, CA 58% 41% 1%
Philadelphia, PA 83% 16% 1%
Pittsburgh, PA 74% 3% 23%
Detroit, MI 96% 4% 0%
Ann Arbor, MI 76% 3% 21%
Orlando, FL 38% 57% 5%
Tampa, FL 77% 22% 1%
 The cost of
chemotherapy in a
hospital outpatient
infusion suite is 24%
higher than in the
physician’s office.1
1 Avelere Health LLC, Total Cost of Cancer Care by Site of Service: Physician Office vs Outpatient Hospital , March 2012
2 Sg2 Site of Service Commercial Claims Analysis, 2012-13
Data powered by

14. Think all providers are the same??
Even providers within the same group will demonstrate
significant variation in practice patterns:
Provider Count Actual Total Cost Expected Total Cost Ratio Episode Count % of total Episodes
1 $88,485 $213,313 0.41 33 9%
2 $194,481 $72,881 2.67 13 4%
3 $38,386 $118,559 0.32 11 3%
4 $10,656 $10,577 1.01 11 3%
5 $30,850 $86,506 0.36 10 3%
6 $27,207 $14,648 1.86 9 3%
7 $62,525 $63,602 0.98 9 3%
8 $18,639 $10,646 1.75 8 2%
9 $33,082 $64,789 0.51 8 2%
10 $256,119 $129,335 1.98 8 2%
2012-2014 Medicare Advantage data for cancer episodes for a single payer and provider group in Central Florida markets.

15. Provider ETG
Actual Total
Cost
Expected Total
Cost
Actual/
Expected Cost
Episode
Count
Actual per
Episode
Expected per
Episode
A Malignant neoplasm of pulmonary system, with active mgmt, w/o surgery $673,782 $674,816 1.00 12 $56,668 $56,755
B Malignant neoplasm of pulmonary system, with active mgmt, w/o surgery $182,602 $170,265 1.07 3 $60,867 $56,755
C Malignant neoplasm of pulmonary system, with active mgmt, w/o surgery $102,650 $127,699 0.80 2 $45,622 $56,755
Variation within episodes
Practice patterns also vary across providers on individual
episodes of care.
Provider Group ETG
Actual Total
Cost
Expected Total
Cost
Actual/
Expected Cost
Episode
Count
Actual per
Episode
Expected per
Episode
A Malignant neoplasm of breast, with active mgmt, with surgery $141,803 $70,431 2.01 4 $33,365 $16,572
B Malignant neoplasm of breast, with active mgmt, with surgery $518,152 $182,237 2.84 15 $35,153 $12,363
C Malignant neoplasm of breast, with active mgmt, with surgery $29,748 $57,382 0.52 3 $9,916 $19,127
2012-2014 Medicare Advantage data for cancer episodes for a single payer and top 3 provider groups in Central Florida markets.

16. Why hasn’t oncology been more front
and center?
Barkley, R, Where Does Oncology Fit in the Scheme of Accountable Care?, J Oncol Pract. Mar 2012; 8(2): 71–74.

17. Is Oncology suited for ACOs?
 Oncologists have well-developed skill
sets in multi-specialty care of
chronically ill patients
 Lots of avoidable cost opportunity
 Cancer patients end up in hospital beds
 Site of care cost differentials

18. Is Oncology Suited for ACO’s? (cont.)
 Low volume/high cost/high variability/high
complexity
 Oncology Care is hard to define and measure
(cancer data immaturity)
 None of the 33 measures have to do w/
Oncology
 Could put patient best interest in
competition with interests of the ACO (new
drugs) – maybe episodes are better?
 Much of the cost is in end-of-life care… not
easy to tackle

19. Does it matter?

20. Advice…
 Pick committed partners
 Signing the contract is just the beginning
 Designate a “go-to” person from each partner
 Speak the same language
 Identify outliers
 Keep the ball rolling
Deirdre Fuller, Oncology Roundtable, The Advisory Board, November 2013

21. Explore with Like-Minded Partners
Organize
Partner
Explore
Find Common Ground…

22. The Role of Clinical Guidelines
ACO or no ACO… it’s a good place to start.

23. Patient-Centered Care
‘Get your own house in
order, even if you aren’t a
member of the
neighborhood association…’1
1Okon, Ted, Cobb, Patrick, Is there a Home for Oncology in ACOs? Practice Update, Cancer Policy Forum (2014).

24. Aligned Financial Incentives
Pay for
Participation
Pay for
Performance
Shared
Savings
Bundled
Payments
Specialty
Capitation
Full Risk
Carve-out
Payer at Risk Provider at RiskShared Risk
VOLUME
VALUE
Improved
Outcomes
Affordability
Clinical
Quality

25. High-Performing Oncology Networks
Evidence-
Based
Medicine
Patient-
Centered
Care
Aligned
Financial
Incentives
MonitorMeasure
Repeat Improve

26. Kelly’s Top 10 Oncology KPIs
Compliance with
Evidence-based
Guidelines
Screening and
Imaging Utilization
ER/IP Admissions
Readmissions
Advance Directives
Patient Satisfaction
EOL Acuity
Pathways Compliance
Generic Prescribing Rate
Total Cost of Care

27. Value-based Cancer Care
“Price is what you pay. Value is what you get.” – Warren Buffett