1 LAN Learnings in July 21 2015 12

1 LAN Learnings in July 21, 2015 12: 00 – 1: 30 pm EDT For Public Distribution

2 Welcome Anne Gauthier, MS LAN Project Leader CMS Alliance to Modernize Healthcare (CAMH) Mark Smith, MD, MBA University of California, San Francisco Previously President and CEO California Health. Care Foundation GC Co-Chair For Public Distribution

3 Agenda • Opening Remarks • Guiding Committee Updates • Promising Payment Practice • Oncology Care Payment Models from United Healthcare and Anthem • Consumer Perspective from National Coalition for Cancer Survivorship • Questions and Answers • Closing Comments For Public Distribution

4 Who is in the audience? (online poll question) What stakeholder group do you represent? For Public Distribution

5 LAN Communications Visit the HCP LAN website For Public Distribution

6 LAN Purpose Goal: In 2016, at least 30% of U. S. health care payments are linked to quality and value through alternative payment models. In 2018, at least 50% of U. S. health care payments are so linked. These payment reforms are expected to demonstrate better outcomes and lower costs for patients. Objectives: §Convene health plans, purchasers, providers, consumers, states and federal partners to establish a common pathway for success §Identify areas of agreement around movement to APMs §Collaborate to generate evidence, shared approaches, and remove barriers §Develop common approaches to core issues such as beneficiary attribution §Create implementation guides for different types of organizations Accelerate the transition to alternative payment models by combining the success of the private sector with the innovation, power and reach of the public sector For Public Distribution

7 June 22 Guiding Committee Meeting GC Charter Future Work Groups • roles and responsibilities • ACO/ACO-like Payment Model; • work that can be accomplished in twoyears • Clinical Episodes Payment Model; • lay the groundwork for longer term change • high-risk/highcost/complex patients First Work Group LAN Engagement • timing, objectives, and approach • importance of transparency • effectively engage LAN participants Full summary at the HCP LAN website For Public Distribution

8 LAN Work Group # 1 APM Definitions and Progress Tracking Work Group Launch Date: July 2015 Objectives • Recommend standard set of operationally meaningful and easily understandable APM terms • Develop an approach for measuring the progress of APM adoption Members • Chair –Sam Nussbaum appointed • 12 -15 members invited to serve LAN Engagement • Affiliated community listserv • Share interim results For Public Distribution

9 Stakeholder Event Help us shape this event at the LAN Summit website For Public Distribution

10 Your Questions What other questions do you have about the Guiding Committee update? Use the chat window in your webinar dashboard For Public Distribution

11 Cancer Care Payment Models With a Consumer Perspective Lee Newcomer, MD, MHA Senior Vice President, Oncology, Genetics and Women’s Health United. Healthcare Jennifer Malin, MD, Ph. D Staff Vice President, Clinical Strategy, Anthem Shelley Fuld Nasso, MPP Chief Executive Officer, National Coalition for Cancer Survivorship For Public Distribution

Episode Payments for Cancer Therapy Lee N. Newcomer, MD 12

Episode Payments for Cancer United. Healthcare launched an episode payment pilot in 2009 focused on oncology services Rewards physicians for improved quality and reduction in total cost of cancer Separates oncologist’s income from drug sales Builds a learning system to identify best practices for cost control and quality 13 Proprietary information of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group.

The Methods Selection of preferred chemotherapy regimen for 19 episodes in breast, colon and lung cancer Calculation of drug profits from those margins Draw a line in the sand Payment fee for service. • Drugs paid at average sales price. • Episode payments unchanged with drug changes. Measure performance annually. Episode payment changes only with lower total cost or improved outcomes 14

Episode Payments for Cancer Results for 810 patients 34% reduction of total medical costs $33 M 179% increase in chemotherapy drug costs $7 M 15

Average Total Cost of Care per Episode Breast Stage I, II HER 2 -, ER+/PR+ (PC 5) 16 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group.

Complications: Emergency Dept. / Hospitalization Lung Adjuvant and Metastatic 17 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group.

Overall Survival from Date of Condition Enrollment Non-Small Cell Lung Stages M 1 a, M 1 b, Non-Squamous (PC 18) Number of Episodes EOC Clinics - 76. 4 National - 841. 7 18 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group.

1. , doi: JOP Journal of Oncology Practice Publish Ahead of Print, published on July 8, 2014 as doi: 10. 1200/JOP. 2014. 001488 19

What We Learned 1. We can reduce costs and improve quality 2. Collaboration is critical for success • Sharing data and measures • Seeking solutions without shame • Focus on the patient 3. Contemporary controls necessary for measurement 4. It’s hard work 20

Cancer Care Quality Program Jennifer Malin MD Ph. D Staff VP Clinical Strategy

Cancer care largely funded through “buy and bill” Oncology Practice Revenue Sources Systemic Therapy is One Third of Cost Towle et al. JOP 2014; 10: 385 -406 Anthem affiliated health plans internal data 2013 MD Visits 3% Other outpatient; 11% Hospitalizations 18% Chemotherapy; 31% Radiation Oncology; 13% Surgery; 17% Diagnostic Imaging; 8% Reimbursement model must change so that focus shifts to cancer care that is value-based and patient-centered 22

Our Model: a Quality Initiative • • • Anthem’s Cancer Care Quality Program provides a framework for rewarding high quality cancer care Oncologists participating in the Cancer Care Quality Program will receive additional payment for treatment planning and care coordination when they select a treatment regimen that is on Pathway Web-based platform with decision-support for Quality Initiative also improves efficiency of review against Health Plan Medical Policy and decreases administrative burden for practices www. cancercarequalityprogram. com 23

Little variation in patient outcomes but marked variation in treatment cost Treatment Estimated Survival (months) Deaths on Rx (Deaths due to Rx) Cost (4 cycles) Carbo/Paclitaxel 13. 0 (NR) <1% (<1%) $452 10. 4 (9. 6 -11. 2) 7% (1%) $886 Gem/Cis 11. 8 (10. 4 -13. 2) 7% (1%) $25, 619 13. 1 (NR) <1% (<1%) $24, 740 Carbo/Paclitaxel /Bev 13. 4 (11. 9 -14. 9) 5% (4%) $39, 770 Carbo/Pemetrex ed/Bev 12. 6 (11. 3 - 14. 0) **2% $64, 988 Cis/Pemetrexed Carbo/nab. Paclitaxel This Pathway is specific for patients who do not have mutations such as EGFR, ALK – Pathways are personalized to tumor biology and genomics If the oncologist or patient determines that a different regimen is better for their unique circumstances, they are still treated according to their preference – Pathway adherence does not impact coverage determination 24

Little variation in patient outcomes but marked variation in treatment cost Treatment Carbo/Paclitaxel Gem/Cis Cis/Pemetrexed Carbo/nab. Paclitaxel Estimated Survival (months) Deaths on Rx (Deaths due to Rx) Cost (4 cycles) 13. 0 (NR) <1% (<1%) $452 10. 4 (9. 6 -11. 2) 7% (1%) $886 11. 8 (10. 4 -13. 2) 7% (1%) $25, 619 13. 1 (NR) <1% (<1%) $24, 740 5% (4%) $39, 770 **2% $64, 988 Carbo/Paclitaxel/ 13. 4 (11. 9 -14. 9) Bev Carbo/Pemetrex ed/Bev 12. 6 (11. 314. 0) This Pathway is specific for patients who do not have mutations such as EGFR, ALK – Pathways are personalized to tumor biology and genomics If the oncologist or patient determines that a different regimen is better for their unique circumstances, they are still treated according to their preference – Pathway adherence does not impact coverage determination 25

Approach to Pathway Development Clinical Evidence & Compendia Clinical Guidelines & Plan Medical Policies Pathways Data from trials, publications, and compendia for many different patient populations are extracted, reviewed, and analyzed. Medical evidence is synthesized by national experts into clinical guidelines. Evidence is also used by health plan committees to develop medical policies and utilization management guidelines used in making benefit coverage determinations. Pathways are a subset of regimens supported by evidence and clinical guidelines and aligned with health plan medical policies. Pathways are intended to be applicable for 80%-90% of patients and are selected based on: 1. Clinical benefit (efficacy) 2. Side effects/toxicities (especially those leading to hospitalizations & impact quality of life) 3. Strength of national guideline recommendations 4. Cost of regimens Anthem’s Pathways are developed through a rigorous evidence based medicine process and reviewed by external advisors. 26

Impact of enhanced reimbursement and support for Pathways Mean Practice Revenue across regimens without S code $ 3, 010 (SD $1, 488) with S code $ 3, 943 (SD $1, 230) v Pe m et re xe d/ l/B ta xe Ca rb o/ Pa cli o/ Be ev l xe ta cli rb m /C Ge ta cli Pa o/ rb is l xe Be Ca em et re xe d/ ev l/B Ca rb o/ rb Ca o/ P Pa cli bna o/ rb ta xe ta cli Pa et xe re xe d is em Ci s/ P Ge xe ta cli Pa o/ rb Ca m /C Ca Ca $b. Pa $- na $ 1 000 re xe d $ 1 000 o/ $ 2 000 et $ 2 000 rb $ 3 000 Ca $ 3 000 em $ 4 000 s/ P $ 4 000 Ci $ 5 000 v $ 5 000 l $ 6 000 S code reimbursement decreases variation in revenue across regimens 27

Perspectives Your approach is a kinder, gentler approach. How can we assess care planning is done? How can you ensure oncologists aren’t just checking a box to get the fee? What is the process measure? How do we get the physician to educate the patient on palliative care? Pathways are the future and adhering to pathways will enhance revenue. Also cost containment by the insurance company -- until our physicians who have practice evidence based medicine for years sees the pathways we will not know how well they follow NCCN preferred guidelines. Use cheaper drugs In theory this seems like a good program for physicians to not lose money on chemotherapy drugs because the reimbursement for the S-code will help recoup some of the loss. Wonderful speakers and webinar. Anthem is going to have treatment pathways to help us provide the most effective treatment for the patients. I don't like the concept a whole lot but it's where things are going so it was helpful to have the information Anthem Cancer Care Quality Program is aimed to increase quality of care, and reduce the cost of care by using proven treatments for fighting cancer. What you have basically is a comparative effectiveness approach. Progressive and forward thinking. I am hoping this helps expedite the authorization process for our patients. Anthem is making providers to follow pathways If every payer wants us to follow their pathways, the practice will not be able to manage the administrative burden I was hoping that some Rad Onc would be mentioned as it often is used in conjunction with chemotherapy Changes forthcoming. Would prefer hard reimbursement numbers. AIM is one of the most, if not THE most, user friendly and speedy prior authorization websites around, especially for getting prior auth for some of our most urgent cancer patients. Source: Feedback provided by practices attending Anthem webinars 28

Program growth since July 2014 Source: AIM Specialty Health 29

Quality Improvement • Practices will receive quarterly reports on quality measures § Pathway Adherence § ER and hospitalizations § NQF End of Life Measures § Phase 2 will include measures of quality of supportive care and genomics • Over time anticipate shifting reimbursement for S code based on performance 30

Value for all stakeholders • • Quality affordable cancer care • Encourages clinically meaningful therapeutic innovations Reimbursement for providers aligned to achieve desired outcomes 31

Cancer Care Payment Reform: A Patient Advocate Perspective

ABOUT NCCS Our mission is to advocate for quality cancer care for all people touched by cancer We represent cancer survivors in public policy efforts to improve cancer treatments and enhance access to quality cancer care Our goal is to foster a cancer care system that is evidence-based, quality-driven, patient-focused and affordable and accessible to all We convene cancer advocates, industry, payers, professional societies, academia and providers We champion cancer care planning, at diagnosis and at major transition points during treatment and survivorship

SOURCE IOM (Institute of Medicine). 2013. Delivering high-quality cancer care: Charting a new course for a system in crisis. Washington, DC: The National Academies Press.

ADOPTION OF CANCER CARE PLANNING: DELIVERY & PAYMENT REFORMS Payment Patient • Prepare patients to be engaged partner • “Take Charge of Your Cancer Care” tools • Legislation – establish a Medicare benefit • Regulation (CMS) • Alternative payment models (CMMI’s OCM) • Private Payers Our Goal • Engaged patients, shared decision-making • Cancer care planning, at diagnosis and at major transition points during treatment and survivorship Providers • Standards & Guidelines • Journey Forward Survivorship Planning Tools

DELIVERY & PAYMENT REFORMS ESSENTIAL TO QUALITY IMPROVEMENT § NCCS considers changing the conversation between doctor and patient as the essential foundation of delivery reform § Payment reforms must be aligned to improve communication, treatment decision-making, symptom management, and coordination of care

NCCS PRINCIPLES FOR PATIENTCENTERED PAYMENT REFORM § Reward quality of services, not just quantity § Require shared decision-making and a cancer care planning process, including advance care planning § Promote evidence-based care by encouraging adherence to guidelines, quality measures, and standards of care § Include consideration of clinical trial options, where appropriate, in the care planning discussion

NCCS PRINCIPLES FOR PATIENTCENTERED PAYMENT REFORM § Communicate patient cost-sharing responsibilities as part of the care planning process § Include protections against underutilization or overutilization § Incorporate outcome, process, and patient-reported outcome measures, developed with input from patients § Ensure that therapeutic innovations will be rapidly incorporated into the standard of care § Reimburse for coordination of care, from screening through survivorship

39 Questions for any of the presenters? Use the chat window in your webinar dashboard For Public Distribution

40 Upcoming Webinars Monthly “LAN Learnings” webinars For Public Distribution August 17, 2015 12: 00 EST September 9, 2015 4: 30 EST November 4, 2015 2: 30 EST December 2, 2015 3: 30 EST

41 Thank You for Participating! The slides and recording from the webinar will be posted to the HCP LAN website. Please fill out the evaluation form. If you haven’t already, register for the LAN at: http: //innovationgov. force. com/hcplan Questions? Email Payment. Network@MITRE. org For Public Distribution