Society of Gynecologic Oncology Member Forum Speakers & Verbal - - PowerPoint PPT Presentation

Society of Gynecologic Oncology Member Forum Speakers & Verbal Disclosures

Carol L. Brown Laurel W. Rice Patrick Timmins Steve Rose None Eva Chalas Speaker Astra Zeneca Clinical trials funded by Astra Zeneca, Pfizer, Clovis Angeles Alvarez-Secord Robert Holloway Speaker honoraria Intuitive Inc. AstraZeneca, Clovis, Jannsen Renata Urban Emily Ko Amanda Jackson Jason D. Wright Elizabeth Jewell Covidien-speaker, teacher laparoscopic courses Laura Havrilesky Research Grant Astra Zeneca

SGO Member Forum

Welcome everyone! will cover critical and important issues to your practice and future of our specialty – MACRA

• What you know and don’t know about MACRA ( Angeles Alvarez-Secord, Renata Urban,

Amanda Jackson)

• What you need to know about MACRA and how you can comply for 2017 (Elizabeth Jewell,

Eva Chalas,Robert Holloway, Steve Rose, Patrick Timmins)

• Why you need to know it: ACA may go away, MACRA is here to stay!

– Endometrial Cancer APM Update ( Emily Ko, Laura Havrilesky, Jason D. Wright) – GYN Clinical Trials Crisis ( Laurel W. Rice) We have great speakers, audience participation, and lots of time for Q&A, so lets get started!

What do SGO Members know about MACRA?

• 37% of SGO members don’t know anything!
• Here is your pre test

– What does MACRA stand for? – If given a choice between complying with MIPS in 2017 or attending another 80s SGO Party which would you choose? – Does APM stand for: advanced practice metrics, advanced payment model, or all popsicles melt?

MACRA establishes two paths for receiving payment adjustments in the future.

Introduction to MIPS and APMs

Merit-based Incentive Payment System (MIPS) Alternative Payment Models (APMs)

• Providers who participate in APMs may

receive a 5% lump sum incentive payment

• Only participation in certain APMs will exclude

providers from MIPS

• Includes programs such as Accountable Care

Organizations

• At least 25% of Medicare revenue must come

from an APM to be eligible for an incentive payment in 2017 and 2018

• MIPS payment adjustments are percentage

increases or decreases to the physician fee schedule

• Each clinician will receive an individual MIPS

score, but may report as an individual or a group

• The MIPS score is compared to national

averages to determine a payment adjustment

• MIPS scores will be shared publicly via

Physician Compare In 2017, all AHS providers will report for MIPS

High Level MACRA Timeline: 2017 - 2019

Oct 3

Last day to begin MIPS reporting to complete minimum 90 day reporting period in 2017

Mar 31

Deadline to submit data for MIPS in 2017

July 2017

Anticipated deadline to enroll providers in AAPMs (MSSP 2 and 3) for 2018

2017 2018 2019 July 2018

Anticipated deadline to enroll providers in AAPMs (MSSP 2 and 3) for 2019

Jan 1

Start of 2018 Performance Period

Key Takeaway: There is only one opportunity per year to increase APM participation

MACRA Plan from a Large Private Hospital System: employed model

Robert W Holloway, MD, FACOG, FACS

• Prof. UCF College of Medicine & Asst. Prof. FSU College of Medicine

Director Gynecologic Oncology Florida Hospital Cancer Institute Orlando, Florida robhollowaymd@gmail.com

MACRA Landscape at AHS

1. Medicare Shared Savings Program (MSSP) Track 2 2. MSSP Track 3 3. Next Generation Accountable Care Organization (ACO) Model 4. Comprehensive Primary Care Plus (CPC+)

Source: Public Law 114-10 (April 16, 2015), CMS, Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR), July 2016

Vast majority of providers are NOT participating in APMs in 2017

% of employed providers participating in APMs % of employed providers not participating in APMs

5. Comprehensive End-Stage Renal Disease (ESRD) Care (CEC) - Large Dialysis Organization (LDO) arrangement 6. Comprehensive ESRD Care Model (non-LDO arrangement) 7. Oncology Care Model (OCM) two- sided risk arrangement

2017 Advanced APM Options

Adventist’s Response to MACRA

• Task Force: AHS has established a MACRA task force to manage the organization’s response to MACRA for both

employed and CIN providers.

• MIPS in 2017: The vast majority of AHS providers will be subject to MIPS in 2017)
• Deloitte Engagement: Deloitte was engaged to support AHS in MACRA preparation by assisting in developing an

education plan for providers and executives as well as assessing potential MIPS performance

HOW ADVENTIST IS RESPONDING TO MACRA HOW ADVENTIST WILL SUPPORT YOU

• Education: AHS will continue to provide relevant training and education to keep you up to date on everything you need

to know about MACRA and MIPS

• Communication: AHS will release communication via emails, newsletters, and webinars to inform you of any important

new rules or changes to the law

• MACRA Helpline: AHS will establish a MACRA help desk rule to answer your questions and help you manage MIPS

reporting

• Long-Term Commitment: AHS is committed to supporting both employed and CIN providers using Athena, Cerner

and eCW in 2017 and beyond

MIPS Reporting at Adventist

Existing Available for 2017

AHS is leveraging Athena and Cerner to report on the following for MIPS Quality Cost Improvement Activities Advancing Care Information Report 6 measures

(From a possible 83 measures)

No reporting required

(This category has no weight in 2017)

Report up to 4 activities

(With 11 expected to be met through use of Athena)

Report up to 11 measures

(Measures are the same as 2016 Meaningful Use) The goal of MIPS reporting is to maximize payment adjustments for the most providers *90 day reporting period necessary

Considerations When Deciding How To Report for MIPS

• TIN Revenue – TINs with small revenue may be excluded from MIPS and/or the revenue at stake is not sufficient

to warrant action in certain performance categories

• Number of Providers – In some instances it may make sense to do individual reporting to avoid having to report

for providers who are excluded

• Reporting Period – Minimum is any continuous 90 day period, maximum is the entire calendar year. The

reporting period can be different across performance categories (i.e. Q1 for Quality, Q4 for ACI)

• Minimum Reporting Requirements – Submitting any one of the following will prevent a negative adjustment:

– 1 Quality Measure, – 1 Improvement Activity, OR – 4 ACI Measures (Risk Assessment, eRx, Timely Access, Summary of Care)

• Reporting Process – We currently do not know how easy/difficult it will be to actually submit data

Experience at an Academic Institution

Steve Rose University of Wisconsin

Quality Payment Program

Begins in 2019: First Performance Year is 2017 Establishes Two Payment Tracks

The Merit-based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APMs)

• Advanced APM Criteria:

– Participants must use certified EHR technology – Payment must be based on quality – Must bear more than nominal financial risk (two-sided risk)

• Additional Incentive for significant

participation in Advanced APMs

• Groups participating in Advanced

APM are exempt from MIPS

• Combines Multiple CMS Programs

– Physician Quality Reporting – Meaningful Use* – Value Based Payment Modifier

• Provides for Incentives/Penalties
• Budget Neutral
• Four Scoring Categories

– Quality – Cost – Advancing Care Information – Clinical Process Improvement

*Does not impact Medicaid or Hospital Meaningful Use Programs

UW Health

• Shared savings program, but track 1

– Not eligible for Advanced APM

• Participating in MIPS in 2017

MIPS Scoring Models

2019 MIPS Scoring 2019 APM Scoring Standard Category Definition Quality Quality Measures Cost Calculated by CMS based on Claims CPIA Clinical Process Improvement Activities ACI Advancing Care Information (Meaningful Use)

• Preferential Scoring for APM participation (APM Standard Scoring)
• Not scored on Cost
• Automatic Bonus Points in CPIA category
• Quality benchmarks for MIPS & APM Standard same as MSSP

UW Health Preparation

Moving forward on both tracks

• Advanced APM

– Applied for Next Generation ACO. – If accepted, 1st performance year will be 2018

• MIPS Standard Scoring

– Continue to prepare for MIPS group reporting in 2017

• ACO data submission for 2017 performance year
• Continue preparation for Meaningful Use Stage 3 and ACI

– Hospital and Medicaid – Stage 3 : Target 2018 – ACI – Target 2017

–

Prepare to submit CPIA activities for 2017 performance year

MIPS Scoring Categories

Category Description Maximum Possible Points Example % Overall MIPS Score Quality If ACO, use ACO Quality Measures 80-90 points ACO Data submission points will be assigned to all UW Health clinicians who are eligible for MIPS 50% Advancing Care Information (ACI) Meaningful Use Measures 100 points

• Base Score – 50 points
• Performance Score for ‘Sending

secure message to patients =50% converts to 5 points

• 1 – 10 points for each measure

25% Clinical Practice Improvement Activities Groups can choose from 90 Activities 60 points

• Participation in UW Health ACO

(MSSP-ACO) = 50 points

• UW Health Anti-coagulation program

= 20 points 15% Cost Claims based measures Average Score

• Medicare Spending Per Beneficiary
• Hospital Readmission Measures

10%

MACRA Plan from a Private Practice Perspective

Patrick F. Timmins, III, MD, FACOG, FACS Women's Cancer Care Associates Albany, NY ptimmins@womenscancercareassociates.com

MIPS and OCM

• We are participating in the Oncology Care Model

(OCM) which qualifies as an APM under MIPS.

• The OCM requires reporting on quality measures and

various practice improvement activities.

• OCM practices like ours that bear one-sided risk are
• nly required to report Advancing Care Information

under MIPS.

Pick Your Pace in 2017

• CMS has designated 2017 as a “pick your pace” year. In order

to avoid the 4% reimbursement penalty in 2019, must report

• n at least one measure in any of the three categories.
• Practices may earn a positive payment adjustment by

reporting on more measures through the year.

• WCCA has chosen to report on as many measures as possible

throughout 2017.

Reporting Options

• Providers can choose to report as individuals or as a group.
• WCCA has chosen to report as individual providers. Each

provider will be held accountable for his/her performance.

• We plan on utilizing ASCO’s Quality Oncology Practice

Initiative (QOPI) platform to manually report measures to CMS.

Response to MIPS

WCCA is focusing on the following improvement activities in 2017

A. Continue to customize our EMR to provide more reportable data. B. Use data for quality improvement (looking at adverse outcomes after surgery, ED utilization, care pathway variances, etc). C. Proactive management of patient symptoms and health maintenance through palliative care, clinical decision support tools, and survivorship programs. D. Develop stronger relationships with community resources. E. Enhance patient portal capabilities and promote patient usage. F. Engage patients and caregivers in all aspects of care. G. Evolve our practice culture leaning towards quality improvement and patient engagement.

The Endometrial APM

Preoperative Care Surgery Postoperative Care

• Lab Studies
• Imaging
• Preop Testing
• Hysterectomy

route

• LOS
• Complications
• Staging and

Lymph node assessment

• Complications
• Readmissions
• ED Visits
• Low risk patients (endometrioid histology, stage I-II)
• Trigger based on stage/histology of surgical

specimen

• Incorporates surgical, preoperative, postoperative

care

• Attribution of care (preoperative) to the primary

Trigger for bundle:

• Meets stage/histology criteria

60 days PostOp

National Trends

N (%) Conversion rate Abdominal 18,852 35.4%

• Laparoscopic

9609 18.0% 9% Robotic-assisted 24,766 46.5% 2.3%

2010-2012 NCDB Data. Stage I/II endometrioid tumors (n=53,277 known surgical modality). In 2012 abdominal hysterectomy decreased to 27.6%.

Base Case Cost

Laboratory (2.4%) Radiology (4.1%) Facility cost (47.2%) Professional cost (16.3%) ER/readmission (7.0%) SNH/home health (0.7%) Other physician cost (2.2%) Unexplained (18.2%)

Mean reimbursement $30,839

Medicare Cost Data

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Average costs for Rob/Lap/Abd/Vag ($18,936) Average costs for Rob/Lap/Abd($19,183) Average Costs for Robotic ( $20,179) Average Costs for Laparoscopy ($14,471) Average Costs for Abdominal ($25,553) Average Costs for Vaginal ($10,995) Average costs for Rob/Lap/Abd/Vag ($18,936) Average costs for Rob/Lap/Abd($19,18 3) Average Costs for Robotic ( $20,179) Average Costs for Laparoscopy ($14,471) Average Costs for Abdominal ($25,553) Average Costs for Vaginal ($10,995) OutPat Lab 426 430 457 390 470 285 OutPat Diagnostic Radiology 542 542 473 529 611 570 OutPat ER/HOSP 2972 2930 2582 1826 4880 4658 SNH/Rehabiliation/Home Health 53 55 22 24 124 Other Physician visits 1170 1182 1270 1228 1026 934 Facility Surgery Cost 10051 10207 11325 7075 14193 4096 Professional Surgery Cost 2281 2307 2296 1920 2912 1203 Remaining Cost 2150 2172 2301 2216 2010 1218

“Optimized” Care

MIS rate increased 5% LOS reduced 10% for new case mix ER visits/readmission reduced 10% for new case mix

*National estimates from 35% abdominal/18% laparoscopic/47% robotic to 30%/20%/50%

$980 (3.2%)

5000 10000 15000 20000 25000 30000 35000

Initial Optimized Remaining Cost Professional Surgery Cost Facility Surgery Cost Other Physician visits SNH/Rehabiliation/Hom e Health OutPat ER/HOSP OutPat Diagnostic Radiology

Endometrial Cancer Pathway

Genetics/Surv eillance Preoperative Care Surgery Postoperative Care Downstream Care Adjuvant Therapy Recurrence Treatment

• Lab Studies
• Imaging
• Preop Testing
• Hysterectomy

route

• LOS
• Complications
• Staging and

Lymph node assessment

• Complications
• Readmissions
• ED Visits

Management Fee: Disease evaluation $200 Management Fee: Preoperative care coordination $200 Management Fee: Postoperative care coordination (weeks 0-2) $200 Management Fee: Postoperative care coordination (weeks 2-8) $200

Clinical Trials in Gynecologic Oncology: Forward Motion

Laurel Rice

Why the Decline?

• Multifaceted

– NIH budget cuts – Restructuring of NCI-sponsored cooperative groups, with formation of NRG Oncology. – Shifting emphasis to smaller biomarker-driven studies.

• The NCI is focused on supporting innovative high impact/low

volume trials.

Total Enrollment for Domestic Extramural NIH Clinical Research FY2008-FY2012 (5-Year Trend)

Fiscal Year Total Enrollment Total Number of Women 2008 11,797,605 7,618,658 2012 11,066,707 6,173,108 % Decrease 6.2% 19%

http://orwh.od.nih.gov/research/inclusion/pdf/Inclusion-ComprehensiveReport-FY-2011-2012.pdf

#1 Training the Next Generation of Scientists in Clinical Trial Design Working Group

– Establish the Young Scientists Clinical Trials Design Network. – Follow-up Meeting/Training Session in Fall 2017.

• NCI is committed to the training and retaining of young

scientists in our field. – The SGO’s Foundation for Women’s Cancer leverages its highly successful Research Grants and Awards Program to offer a named junior faculty research grant.

SGO Legislative/Congressional Ambassadors Continue to Expand (both number and spheres of influence)

• Education of Congressional Offices on Clinical Trials Crisis

– 150+ SGO members are in contact with their Member of Congress’

• ffices, stressing the importance of increased support to the NCI.
• Education of Patients and Advocates
• Expand and integrate our network, create formal coalition structure
• Use new technology, such as Voter Voice, that will improve

efficiencies and streamline processes for patients to communicate with Congress. –

Patient Advocacy Working Group

• Expand and more effectively engage/integrate our

Patient Advocacy Groups – local, state and national to work together.

– Outreach to NCI, providing support. – Outreach to other organizations with influence. – Build a more effective interface with Ambassadors.

Communications Working Group

• Virtual Media Campaign

– Create a virtual media tool-kit:

• Sample tweets
• Outlines for twitter storms
• Tweeting to Members of Congress, the new

Administration, advocates, media, etc. – Facebook graphics and videos – add to the content for Facebooks, including graphics, videos of patient stories, etc.

FORWARD MOTION!

The Endometrial APM

Preoperative Care Surgery Postoperative Care

• Lab Studies
• Imaging
• Preop Testing
• Hysterectomy

route

• LOS
• Complications
• Staging and

Lymph node assessment

• Complications
• Readmissions
• ED Visits
• Low risk patients (endometrioid

histology, stage I-II)

• Trigger based on stage/histology of

surgical specimen

• Incorporates surgical, preoperative,

postoperative care

Trigger for bundle:

• Meets stage/histology criteria

60 days PostOp

National Trends

N (%) Conversion rate Abdominal 18,852 35.4%

• Laparoscopic

9609 18.0% 9% Robotic-assisted 24,766 46.5% 2.3%

2010-2012 NCDB Data. Stage I/II endometrioid tumors (n=53,277 known surgical modality). In 2012 abdominal hysterectomy decreased to 27.6%.

Base Case Cost

Laboratory (2.4%) Radiology (4.1%) Facility cost (47.2%) Professional cost (16.3%) ER/readmission (7.0%)

Mean reimbursement $30,839

Medicare Cost Data

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Average costs for Rob/Lap/Abd/Vag… Average Costs for Robotic ( $20,179) Average Costs for Abdominal ($25,553) Average costs for Rob/Lap/Abd /Vag ($18,936) Average costs for Rob/Lap/Abd ($19,183) Average Costs for Robotic ( $20,179) Average Costs for Laparoscopy ($14,471) Average Costs for Abdominal ($25,553) Average Costs for Vaginal ($10,995) OutPat Lab 426 430 457 390 470 285 OutPat Diagnostic Radiology 542 542 473 529 611 570 OutPat ER/HOSP 2972 2930 2582 1826 4880 4658 SNH/Rehabiliation/Home Health 53 55 22 24 124 Other Physician visits 1170 1182 1270 1228 1026 934 Facility Surgery Cost 10051 10207 11325 7075 14193 4096 Professional Surgery Cost 2281 2307 2296 1920 2912 1203 Remaining Cost 2150 2172 2301 2216 2010 1218

“Optimized” Care

MIS rate increased 5% LOS reduced 10% for new case mix ER visits/readmission reduced 10% for new case mix

*National estimates from 35% abdominal/18% laparoscopic/47% robotic to 30%/20%/50%

$980 (3.2%)

5000 10000 15000 20000 25000 30000 35000

Initial Optimized Remaining Cost Professional Surgery Cost Facility Surgery Cost Other Physician visits SNH/Rehabiliatio n/Home Health

Endometrial Cancer Pathway

Genetics/Sur veillance Preoperative Care Surgery Postoperative Care Downstream Care Adjuvant Therapy Recurrence Treatment

• Lab Studies
• Imaging
• Preop Testing
• Hysterectomy

route

• LOS
• Complications
• Staging and

Lymph node assessment

• Complications
• Readmissions
• ED Visits

Management Fee: Disease evaluation $200 Management Fee: Preoperative care coordination $200 Management Fee: Postoperative care coordination (weeks 0-2) $200 Management Fee: Postoperative care coordination (weeks 2-8) $200