from volume to value: maintaining quality and ......1 hicc –june 2017 from volume to value:...

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HICC – June 2017

FROM VOLUME TO VALUE:

Maintaining Quality and Patient Centricity in a

Tough Healthcare Environment

Derek Raghavan MD PhD FACP FRACP FASCOPresident

Levine Cancer Institute

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HICC – June 2017

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PRESIDENTIAL POLITICS HEALTH CARE

WORDS IN COMMON

INTEGRITY SECURITY RELIABILITY

HONESTYTRACK RECORD FIDELITY

BIG DATA

INTEGRATION COST MANAGEMENT

Huntsman-Intermountain Cancer Conference

Problems Needing New Solutions

• Health Care “Reform” Bill struggles through House –

millions will lose insurance if Senate messes up

• New paradigms of value – USA cannot afford current

pattern of expenditure on health care– Costs rising rapidly in cancer care

– Community expectations divorced from reality

• Less than 5% of patients with cancer involved in cancer

trials

• Major problems with disparities of care– Minority populations + language problems

– Impoverished

– Elderly

– Geographically isolated – poor access to best care


A SHARED RESPONSIBILITY FOR THE PROBLEM

• The population and health behavior – smoking, obesity

• Death is an un-American activity

• The medical profession – profits, fear of litigation,

lobbying

• The pharmaceutical industry – profits, lobbying

• Politicians

• The legal profession – profits, lobbying, stirring the pot

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Huntsman Intermountain Cancer Conference

Community Expectations

• The Press – cancer a “hot”

topic

• “War on Cancer” generated

false expectations, regularly

revised as false expectations

• Driven by politicians

• Driven by experts with/ without

skin in the game

– Dartmouth

– Ethicists

• Leapfrog, Press Ganey &

clones – patient surveys

• Conflicts of interest in

government evaluations

• Health Policy “experts”

• Influence of advocacy groups

– Tension between science and

opinion?

– Influence of opinion leaders

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Total hospital and physician

costs, 2013a

Diagnostic imaging

prices, 2013a Price

comparison for

in-patent

pharmaceuticals

in 2010

(U.S. set to 100)bBypass

surgery Appendectomy MRI

CT scan

(abdomen)

Australia $42,130 $5,177 $350 $500 49

Canada — — — $97 50

France — — — — 61

Germany — — — — 95

Netherlands $15,742 $4,995 $461 $279 —

New Zealand $40,368 $6,645 $1,005 $731 —

Switzerland $36,509 $9,845 $138 $432 88

United

Kingdom— — — — 46

United States $75,345 $13,910 $1,145 $896 100

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What’s the

deal in NH?

What’s up

in LA?

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What’s The Story in NH and LA?

• NH:

– Small area

– Educated

– Fewer indigent

– High density academics

– High density proximate

hospitals

– Dartmouth engineers of

healthcare

– Work conditions

– Liberal state

• LA:

– Poverty

– Large state

– Poor access

– Poor education

– African American cultural

issues

– Targeting of advertisers

– Work conditions

– Conservative state


Problems Needing New Solutions

• Health Care “Reform” Bill struggles through House – millions

will lose insurance if Senate screws up

• New paradigms of value – USA cannot afford current pattern of

expenditure on health care

– Costs rising rapidly in cancer care

– Community expectations divorced from reality

• Less than 5% of patients with cancer involved in

cancer trials

• Major problems with disparities of care

– Minority populations + language problems

– Impoverished

– Elderly

– Geographically isolated – poor access to best care


Shifting Models of Specialty Care

Ibrahim & Dimick, NEJM Catalyst,2017


Shifting Models of Specialty Care

Ibrahim & Dimick, NEJM Catalyst, 2017


Academic-Hybrid Center: Definition

• Fusion of teams of academic clinicians and practice

oncologists + laboratory support

• Multi-site distributed throughout the community

• Single/multiple hubs/spokes

• Seamless communication mechanisms

• Centralized Cancer Trials Office & Staff Training

• Centralized IRB – Protocol Review & Monitoring

Presented by:


Why Academic-Hybrid Centers?

• Potentially lower running costs than NCI-designated

cancer centers

• Geographical access

• Less travel for patient

• More support for oncologists in community

• Equity for all patients

• Implementation of survivorship programs via

geographical access and local integration

Presented by:


A practical example: Levine Cancer Institute

• Established 2011

• Carolinas HealthCare System• NC and SC – 40 hospitals, 2000 physicians, 12 million encounters

per year

• Initially 8,000 new cancer cases (quality of documentation variable)

• Levine Foundation initial grant of $25m

• Initial plan to increase size of regional cancer center

Presented by:

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Environmental Assessment 2010

• Large population of patients with cancer

– insufficient organization

– poor access to first-class care and research – particularly for geographically

distant patients

– variable quality of care and patient satisfaction

• Impact of Affordable Care Act

• North Carolina not participating in federal support program

• Increasing numbers of indigent/self-pay/Medicaid/Medicare

• Carolinas Health Care System – safety net

• Increasing costs of care – especially in cancer field

• Greatest cost increment in the elderly

• Problems with access to care and translational research

• Increasing complexity of science and treatment in oncology

• Efflux of patients for routine and complex care


Our Vision – 2010 Playbook:

Changing the Course of Cancer Care

• Unified enterprise-wide network

• Spread across two states

• Patient-centered

• Emphasis on VALUE

• Clinically integrated + research

• Best-practice collaboration across the

enterprise

• Cost considerations

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Levine Cancer Institute – Charter Membership

• AnMed

• Blue Ridge Healthcare

• Cleveland Regional

• CMC

• CMC-Lincoln

• CMC-Mercy

• CMC-NorthEast

• CMC-Pineville

• CMC-Union

• CMC-University

• Roper-St. Francis

• Stanly Regional

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Meticulous Fiscal Planning

• Business plan at the base of each initiative

• Value shift value-driven volume algorithm

• Strong fiscal administrative leadership

• Careful due-diligence on new geographic sites

• Extensive disparities program – offset by 340B pricing

• Pharmacy/pharmacology Committee for drugs

• Increased rigor in structuring of research finance

• Essential services that don’t pay – provided, but with

even tight fiscal oversight


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Structure for Enterprise Engagement &

Collaboration

Enterprise SummitsEducation, Networking/Team Building

Enterprise Cancer Strategy CouncilCoordination of Enterprise Cancer Initiatives

CharlotteRegional Cancer

Strategy Council

WesternRegional Cancer

Strategy Council

LowcountryRegional Cancer

Strategy Council

UpstateRegional Cancer

Strategy Council

Market Development, Regional Tumor Site Planning & Development

2x/Year

Quarterly

Monthly Tumor Site Team Quality

Council

May/Jun 2011

Launch by May 2011

Launching March-April

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LCI Participation Agreement - Elements

• General requirements

– 0.1 FTE for local cancer

program

– Commission on Cancer,

etc.

• Accreditation

• Quality of Care

• Patient Navigation

• Multidisciplinary Conferences

and Tumor Site Teams

• Information Technology

• Data Monitoring and Sharing

• Clinical Research

– Single IRB – Chesapeake

– Active support

• Marketing & Branding

• Healthcare Disparities and

Community Outreach

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RECRUITMENT: Leadership

• Ed Kim MD FACP (MD Anderson)

• Ed Copelan MD FACP (Cleveland Cl)

• Belinda Avalos MD (OSU)

• Steven Akman MD (Wake Forest)

• Jeff Kneisl MD (CHS)

• Richard White MD FACS (CHS)

• Declan Walsh MD FACP FRCP

(Cleveland Cl/Trinity College)

• Antoinette Tan MD FACP (Rutgers/RWJ)

• Jimmy Hwang MD FACP (Georgetown)

• Stuart Burri MD (CHS)

• Roshan Prabhu MD (Emory)

• Steve Riggs MD (EVU)

• Jubilee Brown MD (MDAH)

• Ram Ganapathi PhD (Cleveland Clinic)

• Carol Farhangfar PhD (MD Anderson)

• Jim Symanowski PhD (NCCC)

• Jon Gerber MD (Hopkins)

• Saad Usmani MD FACP (Arkansas)

• Nilanjan Ghosh MD (Hopkins)

• Peter Voorhees MD (UNC Chapel Hill)

• Steve Park MD PhD (UNC Chapel Hill)

• Maryann Knovich MD (Wake Forest)

• Ify Osunkwo MD (Emory)

• Peter Clark MD (Vanderbilt)

• Jeffrey Hagen MD (USC)

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Integration of Function & Standards Crucial

• Establishment of unifying standards and SOPs

• Central IRB, PRMS, Cancer Trials Office

• Tumor-specific teams Electronically Accessible pathways– All oncologists eligible and encouraged to participate

– Electronic design – rapid updating as needed

• Pathways:– Evidence based best practice (ASCO, NCCN, other)

– Cancer trials loaded

– Consent sheets

– Electronic connection to Cancer Trials Office

Presented by:

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Presented by:

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Role of the Oncology

Nurse Navigator

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•Definition: oncology way-finding by experienced nurses•45 navigators•All tumor types

•Distance navigator•Minority navigators

•Developed software•Metrics


Impact of Nurse Navigation

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3

1

50% of cases of ASCO TAPUR trialHalf of these from periphery


Phase I (first-in-man) Clinical Trials

• Variety of different trials needed with different drug pathways

involved

• Multi-site access points reduce need for travel

• Broad molecular marker reflex testing may assist in directing

patients to particular clinical trials

– Funds set aside to assess tissue biomarkers in all phase I patients

– Pharmacogenomic collection

– Reminders on EA Pathways

• Staff: Phase I oncologist research team, PharmD, PA’s

• Commenced July 2014 – 3 sites – Charlotte, Charleston, Concord

• Trials now under way

• Center of Excellence – molecular diagnosis with Caris

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Psychosocial

Examples:

Social Work

Counseling

Support Groups

Psychoeducational Classes

Psychiatry Consultation

Pastoral Care

Financial Counseling

Wellness

Examples:

Exercise Program

Nutrition

Lifestyle Counseling

Tobacco Cessation

Substance Program (AA/NA)

Weight Management

Integrative Oncology

Examples:

Integrative MD Consults

Integrative therapies

Class/Groups/Workshops

Integrative trained Staff

Integrative Research

Medical/Clinical

Examples:

Survivorship Care Plans

Acute Nutritional Interventions

Lymphedema Program

Survivorship Clinics

Incontinence/Impotence Program

Fertility Preservation/Assistance

Rehabilitation Programs

Long Term Survivorship Research

LCI Survivorship & Supportive Care

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Planetree Organization

• International organization established 1978 to advance

patient-centered care

• 82 certified centers world-wide (previously focused on

hospitals)

• Key components:

– Cultural transformation

– Patient activation

– Staff engagement

– Leadership development

– Performance improvement

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Criteria of Assessment

• Hospital infrastructural requirements

• Focus on human independence/dignity

• Patient education, choice and responsibility

• Family involvement

• Dining, food, nutrition

• Healing environment, architecture, design

• Arts and entertainment

• Spirituality

• Integrative environment

• Healthy communities, survivorship

• Measurement

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LCI/Planetree Project – System Wide

• Jill Harrison, PhD – Research

Consultant, Planetree

• Senior Leadership enthusiasm

• Physicians/Management/Staff

education

• Focus Group

feedback/suggestions

• Presentation of assessment to

Providers, management, and staff

• Care for the Caregiver celebration

• Retreats (handwritten invitations)

• Coordination of Steering

Committee/Metrics

• Review by Planetree – 3-4/2016

• Certified 12/2016

Organizational Assessment:Focus Groups

Sustaining

Executive Readiness Sessions

Executive Readiness Sessions

Staff Information Sessions

Organizational Assessment

Kick off Celebration/Facilitator Training

Staff and Physician Retreats

Steering Committee

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LCI Accreditations

• Commission on Cancer (CoC) –outstanding award/Gold

commendation; max. of 8/8 commendations

• ASCO Quality Oncology Practice Initiative (QOPI)

• National Accreditation Program for Breast Centers

(NAPBC®)

• External Advisory Board

• Foundation for Accreditation of Cellular Therapy (FACT)

• Survivorship Training and Rehabilitation Program (STAR)

• American College of Radiology

• Magnet certification for nursing (CHS)

• Planetree Organization – first cancer center accredited

(12/16)

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Disparities of Care: The Problem

Underserved Groups:• African American

• Hispanic

• Rural

• Elderly

• Isolated

• Disabilities

• Immigrant

Indicators of Risk:• Poverty

• Poor education

• Language & literacy barriers

• Lack of insurance

• Isolated geography

• Cultural

• Co-morbidities

• Health system issues

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Levine Cancer Institute Approach to Disparities

• Safety net organization

• All care focused on LCI branches – support from 340B

• All services available to all patients irrespective of

insurance status

• Major focus on outreach and proactive strategies:

– Screening – breast, colorectal, prostate (African American, family

history), and lung (e.g. first mobile low dose CT screening unit)

– Education (e.g. Breast cancer education for Latinas)

– Treatment available to all patients

– Culture of cancer trials being OFFERED

– Cancer Prevention via education and early diagnosis

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• Low dose CT scans• High-risk subjects• Nurse navigation• Education of local docs• Meticulous follow up• Central radiology review

Bristol Myers Foundation grant

44.4%

33.3%

22.2%

Pre-intervention to Post-intervention

Statistically-significant improvement

Non-statistically significant improvement

Non-statistically significant decline

22.2%

66.7%

11.1%

Pre-intervention to Three-month Follow-up




Education of Hispanic Women – Breast Screening

90.0%

10.0%

Pre-intervention to Post-intervention




60.0%

30.0%

10.0%

Pre-intervention to Three-month Follow-up




Risk Factors for Breast Cancer – Education of Hispanic Women


Innovation

• Stem cell biology of leukemia – Gerber assay system

• New drugs/diagnostic work for multiple myeloma – Usmani

• New drugs for melanoma – Amin

• Cancer pathways – electronic – Kim

• Patient reporting APP – Raghavan/Kim/Accenture

• Navigation software – Green (Stanly Regional)

• New drugs for lung cancer – Haggstrom, Mileham, Kim et al

• New approaches to brain cancer – Sumrall, Burri, Asher

• Multisite approach to cancer care – Raghavan et al

• New approaches to surgery – Salo, Iannitti, Hill, Riggs


Free-Standing Academic-Hybrid Centers

SITE New Cases Faculty Open

Trials

Accruals

to Trials

Navigators

ISCI 5350 85 95 205 16

GCC 3200 80 130 690 8

LCI 16,000 120 300 1000 45

Presented by:


Quality Indicators

SITE CoC QOPI ACR TB/mo MTB DISPARITIES

PROGRAM

ISCI + - + 45 + -

GCC + + + 19 + +

LCI + + + 40 + +

Presented by:

CoC – Commission on Cancer; TB – tumor boards; MTB – molecular tumor board

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Value PropositionBENEFITS:

• Standardized care via EA Pathways

• Less travel & inconvenience for

patients

• Local access to sophisticated

survivorship programs & support

• Genetic counseling via telemedicine

stations

• Distributed access to cancer trials –

often with reduced cost of drugs

• Address disparities of care and access

for uninsured/poorly insured

• Fiscal – purchasing, contracting

• Measured outcomes

• System-wide palliative/supportive

medicine integration

• Avoid ineffective therapies - pathways

• DRAWBACKS:

• Increased costs vs. free-standing

offices

• Less physician autonomy

• System vs. individualized???

• On-service in wards

Presented by:

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Addressing Costs

• Multi-site – less travel

• Evidence-based medicine

• Standardized approaches

• Oncology Pharmaceuticals Committee• Cost effectiveness

• Cost vs. price

• Active unit of Supportive/Palliative Medicine – on

Pathways

• Clinical trials on the Pathways

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INSTITUTE OF MEDICINE – CHOOSING WISELY

ASCO Recommendations 2012

• Don’t use cancer-directed therapy for solid tumor patients with low

performance status (ECOG 3-4), no benefit from prior evidence-based

interventions, not eligible for clinical trial, no strong evidence supporting

value of further Rx

• Don’t perform PET, CT and bone scans in staging of early prostate cancer

at low risk for metastasis

• Don’t perform PET, CT and bone scans in staging of early breast cancer

at low risk for metastasis

• Don’t check biomarkers or scans for asymptomatic patients treated for

breast cancer with curative intent

• Don’t use white cell stimulating factors for primary prevention of febrile

neutropenia for patients with less than 20% risk

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Huntsman Intermountain Cancer Conference 5

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Summary

• 2010 Strategy Playbook rapid trajectory of growth

• Improved quality with embedded translational research

• Substantial innovation and research benefits patients

• System engagement of disparities of cancer care programs

• Tight and robust fiscal management– Produces sustainability of ALL services

– Business plan attached to all ventures, focus on value

• Rapid clinical and research expansion at all sites

• Telemedicine – genetic counseling, pain management

• Social/patient focus aspects of medical care still heavily emphasized

• Fellowship training program – populates the environs

• Academic hybrid cancer center is a model that appears to work!!

• NO suggestion of replacing extant models.


The Future Looks Bright!

(always be cautious in prediction)

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from volume to value: maintaining quality and ......1 hicc –june 2017 from volume to value:...

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