Aetna’s Value-Based Process Improvement for the Survival of Community Oncology

May 2013, Vol 4, No 4

Hollywood, FL—Community oncology will not survive in the absence of novel management strategies and process improvements, according to Michael Kolodziej, MD, FACP, National Medical Director of Oncology Solutions, who offered his insights at the Third Annual Conference of the Association for Value-Based Cancer Care.

Figure 1
Figure 1: The Healthcare System Produces $750 Billion in Annual Waste.
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The Institute of Medicine has suggested that approximately 30% of healthcare spending, or $750 billion annually, is “a waste,” he said (Figure 1).

“This is doing things that don’t benefit patients, and it’s lousy care delivery.”

Aetna spends 30.8% ($1.5 billion) of its dollars on medical therapies, 23.3% ($1.1 billion) on inpatient care, 22.4% ($1.1 billion) on radiology, and 9.4% ($483 million) on specialty physicians; these are the top drivers in cancer care at Aetna. Therefore, processes must be implemented that could curb these costs, Dr Kolodziej emphasized.

Evidence-Based Medicine in Every Corner
If integrated into delivery systems, Aetna’s “mantra” of evidence-based medicine would help avoid waste, he proposed. Aetna’s value-based processes focus on evidence-based medicine and include the following prin­ciples:

  • Drive efficient use of evidence-based medicine: this involves platforms that provide content and workflows, integration of evidence-based medicine into the Aetna and provider systems, and simpler administrative processes for providers
  • Avoid the waste and misuse of medical services: this involves better provider alignment, more narrow and tiered networks, and better decision support strategies
  • Leverage and integrate current and future medical and pharmacy cancer-care initiatives: this involves seamless, end-to-end cancer experiences for Aetna members and providers.

Dr Kolodziej and colleagues conducted one of the few studies, if not the only one, to demonstrate that evidence-based medicine is cost-saving (Neubauer MA, et al. J Oncol Pract. 2010;6:12-18). Patients with non–small-cell lung cancer from 8 practices within the US Oncology Network were analyzed. The overall outpatient costs were found to be 35% lower for on-pathway versus off-pathway patients, whereas survival was unchanged.

The study should that treating patients according to pathways was cost-effective across a plausible range of willingness-to-pay thresholds.

Pathways must take into account, however, that different patient subsets have various requirements, Dr Kolodziej added. “HER2-positive breast cancer in a 40-year-old person is different from that in a 70-year-old person. The drugs may be the same, but the resources consumed by these patients are different. Until we get our hands around this concept, we will struggle,” he said. “The patient-centered medical home is a way of dealing with these differences in a way that will improve the outcome of patients.”

Preparing Systems for Novel Payment Models
An Innovent/Aetna pilot program is studying patients enrolled in the Innovent Oncology Program to evaluate the impact of a cancer management program on patients receiving chemotherapy for 1 or 2 years who were seen by Texas Oncology physicians between May 2010 and May 2012. The study is evaluating drug costs, emergency department visits, inpatient admissions, and costs.

A key component of this pilot program is a proactive approach by oncology nurses. Early results show a 12% overall cost-savings in patients with breast, lung, and colon cancers as a result of a reduction in emergency department visits and inpatient days per member. The use of nurses who are trained in end-of-life counseling also enhances timely enrollment to hospice, the data showed. “We have de facto proof of process. If you could execute this strategy, it would work,” Dr Kolodziej maintained.

Figure 2
Figure 2: Oncology Medical Home Solution.
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He acknowledged that the average practice could have difficulty implementing this type of approach. However, Dr Kolodziej said, Aetna is seeking to help oncology practices transition to the new models of value-based care, such as the medical home and accountable care organizations (ACOs). “We will develop tools to assist the practice in executing these strategies and transitioning to a medical home,” he said (Figure 2).

“We can also look to leverage Aetna accountable care solutions to serve oncology practices seeking shared savings through the accountable care organization model,” Dr Kolodziej said.

Aetna will leverage accountable care solutions to facilitate relationships between enabled oncology practices. Aetna prepares hospital systems to become ACOs through an analytical, intellectual process that results in the creation of a value-based plan, he added.

The Current System Must Change
Change must come to the “current state of affairs,” in which the oncologist and his or her office is “stuck in a 20th century communication and data exchange environment” in which collaboration with other healthcare providers is often tedious, costly, and difficult to obtain, Dr Kolodziej maintained.

Figure 3
Figure 3: Creating a More Collaborative Network of Caregivers.
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A fully digital healthcare delivery system, in contrast, makes true collaboration with a network of caregivers possible and fully satisfies meaningful use. For example, the iNexx payer app, Aetna Connect, greatly simplifies the ability of providers to manage their communications with Aetna by consolidating everything through a single point of communication. This brings the right administrative and clinical processes to the physician’s practice, making it easier for practices to conduct their business, he said (Figure 3).

Success, Dr Kolodziej concluded, “will require multiple steps,” that will include:

  • Transformation of clinical practice
  • Evolution of the hospital into an integrated delivery system
  • Adoption of performance measurements and process improvement
  • Modernization of  the health information platform, focused on payer, provider, and patient integration
  • Reformation of the reimbursement platform
  • Partnership.

To improve cancer care and remove the enormous waste in the system, all stakeholders must work together as an integrated system, with the common goal of enhancing patient care by embracing new technologies and improved, evidence-based processes.

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