How To Improve Oncology Margins

Oncology Roundtable
How to Improve Oncology Margins

Maximize revenue, contain costs, and drive growth
Deirdre Saulet
sauletd@advisory.com
2
Road Map
1 A Margin Problem
2 Three Priorities for Cancer Programs
3 Prioritizing for Your Program
©2016 The Advisory Board Company • advisory.com • 32620A

3
A poster child for high costs

National focus on drugs puts cancer—fairly or unfairly—in the spotlight
The New York “The Punishing Cost Growth in costs per patient
Times of Cancer Care” 2004-2014
n=41,098 Medicare cancer patients;
TIME “Cost of Cancer Is n=129,507 commercial cancer patients
Becoming Unaffordable” 63% 62%
The Wall “Insurers Push to Rein in

Street Journal Spending on Cancer Care”
35% 36%
Drug costs on everyone’s radar
increase in average
100% cost of new cancer
drugs from 2007-2017 Medicare Commercial
Cancer Non-cancer
Source: Milliman, “Cost Drivers of Cancer Care: A Retrospective Analysis of Medicare and Commercially Insurerd
Population Claim Data 2004-2014,” April 2016, http://www.milliman.com/uploadedFiles/insight/2016/trends-in-
cancer-care.pdf; IQVIA, “Global Oncology Trends 2018: Innovation, Expansion and Disruption,” May 24, 2018,
©2019 Advisory Board • All rights reserved • WF1088267-a 08/12 https://www.iqvia.com/institute/reports/global-oncology-trends-2018; Oncology Roundtable interviews and analysis.
4
Exacerbated by rising demand

Utilization will increase with aging population, expanding treatment options
Estimated number of new cancer Factors driving increased cancer volumes

cases in the US
In millions 55%
1.94 estimated increase in US
Aging population over 65 years of
population age from 2010 to 2030
1.80
33%
estimated increase in
Lifestyle obesity prevalence in the
factors US from 2010 to 2030
1.63
I
300%
estimated increase in
Treatment
global revenue from cancer
options
2018 2023 2028 immunotherapy market
from 2018 to 2024
Source: Colby SL, Ortman JM, “The Baby Boom Cohort in the United States: 2012 to 2060,” U.S. Census Bureau, May 2014,
https://www.census.gov/prod/2014pubs/p25-1141.pdf; Medicare Chronic Conditions Dashboard, https://www.cms.gov/Research-
Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Chronic-Conditions-State/CC_State_Dashboard.html;
https://www.ajpmonline.org/article/S0749-3797(12)00146-8/fulltext; “Global Cancer Immunotherapies Market to 2024 - Increased
Uptake of Immune Checkpoint Inhibitors Driving Growth, Supported by a Large, Robust Pipeline,” Research and Markets, July
©2019 Advisory Board • All rights reserved • WF1088267-a 08/12 2018, https://www.researchandmarkets.com/research/9rpwcx/global_cancer?w=4; Oncology Roundtable interviews and analysis.
5
Forcing purchasers to double down on spend
Three areas of focus for payers and employers to control costs
1 2 3
Treatment costs Site of care Provider choice

• Drug pricing reform • Site neutrality • Network
design
• 340B reimbursement • Site-of-care
• Prior authorization policies • Centers of
excellence
• Pathways
• Radiation Oncology
Model
©2019 Advisory Board • All rights reserved • WF1088267-a 08/12 Source: Oncology Roundtable interviews and analysis.
6
The margin problem

Expense growth already outpacing revenue growth for most hospitals
Revenue and expense growth rates !
for non-profit hospitals
Traditional financial
2009-2018 medians pressures
8%
Staffing
6%
Drugs and supplies
4%
Capital investments
2%
2010 2012 2014 2016 2018
Service utilization
Revenue growth Expense growth
Source: Moody’s Investors Service, “US NFP & Public Hospitals’ Annual Medians Show Expense Growth Topping Revenues
for Second Year,” August 28, 2018; Moody’s Investors Service, “Revenue Growth and Cash Flow Margins Hit All-Time Lows in
2013 US Not-for-Profit Hospital Medians,” August 2014; Health Care Advisory Board, Toward True Sustainability, Washington,
DC: Advisory Board, 2018; Rege A, “The No. 1 priority for hospital CEOs? Cost control,” Becker’s Hospital Review, July 11,
2018, https://www.beckershospitalreview.com/hospital-management-administration/the-no-1-priority-for-hospital-ceos-cost-
©2019 Advisory Board • All rights reserved • WF1088267-a 08/12 control.html; Oncology Roundtable interviews and analysis.
7
Moving the mark on margin management

Narrowing our focus to three priorities
1 2 3
Control Maximize revenue Prioritize profitable
costs capture growth
1. Reduce unwarranted 4. Use financial reporting 7. Formalize referring

care variation to diagnose gaps physician partnerships
2. Implement acuity- 5. Mount a multidisciplinary 8. Implement a strategy to
based staffing response to site-of-care manage patient reviews
3. Provide proactive pressures 9. Build meaningful
symptom management 6. Invest in comprehensive employer relationships
financial navigation
©2019 The Advisory Board Company • advisory.com • 32620A Source: Oncology Roundtable interviews and analysis.
8
Road Map
1 A Margin Problem

9
Control costs

Opportunity #1: Reduce unwarranted care variation 10
Realizing the importance of care standardization

Which of the following are your cancer program’s biggest opportunities for cost savings?
Percentage of respondents who ranked opportunity in top three, 2018
n=160
Symptom management (e.g., reduce ED visits) 54%
Clinical standardization 54%
Drugs 42%
Care coordination (e.g., navigation) 41%
Non-clinical staff 39%
Technology maintenance 13%
Capital expenses (e.g., LINAC, imaging tech) 11%
Retail pharmacy 8%
Clinical research 6%
Supplies 6%
Patient wellness (e.g., yoga, nutrition) 4%
Clinical staff 4%
Source: 2018 Trending Now in Cancer Care Survey;

©2019 The Advisory Board Company • advisory.com • 32620A Oncology Roundtable interviews and analysis.
11
Despite benefits, uptake of pathways still limited
Demonstrating the Cost Savings

Not Widespread
P4 Pathways and Care First BCBS¹ Pilot
Reduction in total costs for Of Oncology Roundtable
15% the treatment of breast, lung, 25% members use pathways
and colon cancer patients for medical oncology
treated on pathway
Value Pathways² and Aetna Pilot

Common Barriers to Adoption
Difference in annual outpatient
35% cost for NSCL cancer for • Additional steps to physician workflow
patients treated on pathway
• Physician concerns about lack of
transparency into pathway development
Deloitte Study • Diminished opportunity for shared
Estimated³ reduction in drug spend
30% if stage I breast patients were
decision making
• Concerns that selected pathway will not
treated on clinical pathway; savings
estimated at $21,900 per episode align with payer strategy
Source: Neubauer M, et al., “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non-Small-Cell
1) Blue Cross Blue Shield. Lung Cancer in the Community Setting,” Journal of Oncology Practice, 6, (2010): 12-18; Kreys ED, et al., “Documenting the
2) Previously known as Level I Pathways. Benefits and Cost Savings of a Large Multistate Cancer Pathway Program from a Payer’s Perspective,” Journal of Oncology
3) Using Truven MarketScan29. Practice, 9, (2013); Reh G, et al., “The Evolution of Oncology Payment Models: What Can We Learn from Early Experiments?”
Deloitte, https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/oncology-payment-models.html; Medical
©2019 The Advisory Board Company • advisory.com • 32620A Oncology Vol. Staff. Ops. Survey; Oncology Roundtable interviews and analysis.
12
Taking a homegrown approach

Dana-Farber commits resources to develop their own pathways
Overview of Clinical Pathways Development at Dana-Farber
Discussed importance Partnered with Via Implemented

of clinical pathways at Oncology to use the pathways into
retreat Via online platform practice
Year 1 Year 2 Year 3 $17,085

Reduction in total
adjusted costs per
Created pathways team Created and integrated
patient over 12 months
comprised of medical homegrown clinical
director, operations director, pathway for NSCLC
three project managers, and stage IV patients
a data analyst
Source: Jackman D, et al., “Cost and Survival Analysis Before and After Implementation of Dana-
Farber Clinical Pathways for Patients with Stage IV Non-Small Cell Lung Cancer,” Journal of Oncology
Practice, (2017), http://ascopubs.org/doi/pdf/10.1200/JOP.2017.021741; Dana-Farber Cancer Institute,
©2019 The Advisory Board Company • advisory.com • 32620A Boston, MA; Oncology Roundtable interviews and analysis.
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Proposal for radiation APM just released

Five-year pilot projected to begin either January 1 or April 1, 2020
Radiation Oncology Model basics
• Will require participation from providers (including physician group practices, hospital outpatient
departments, and freestanding centers) within randomly selected Core Based Statistical Areas
• Providers treating beneficiaries with one of the 17 included cancer types will receive prospective
payments for a 90-day episode of care
• Broken into professional component and technical component payments
• Amounts based on proposed base rates, trend factors, and adjustments for participant’s case-
mix, historical experience, and geographic location
• CMS will apply a discount factor of 4% for professional component and 5% for technical
components
• Participants can earn back withholds based on clinical data reporting, quality measure reporting
and performance, and the CAHPS Cancer Care Radiation Therapy Survey
• Will qualify as an Advanced APM and MIPS APM
Check out Your top questions on the Radiation Oncology Model, answered for more information
Source: Hubbard A, “RO-APM: What we know, what we don’t and what it all
means,” ASTRO Blog, February 14, 2019, https://www.astro.org/Blog/February-
2019/RO-APM-What-we-know,-what-we-don%E2%80%99t-and-what-it-all;
©2019 The Advisory Board Company • advisory.com • 32620A Oncology Roundtable interviews and analysis.
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Changing practice step by step

Incremental changes to pathways encourage hypofractionation
Major Milestones in Breast Clinical Pathway Development at UPMC
January Year 1 Amendment 1 January Year 2 Amendment 2 January Year 3 Amendment 3

HF-WBI1 first option for women HF-WBI first option for women HF-WBI only pathway concordant
70 or older with stages 0-IIA, 50 or older with stages 0-IIA, option for women 50 or older with
CF-WBI2 pathway concordant CF-WBI pathway concordant stages 0-IIA, CF-WBI use requires
secondary option secondary option peer review and justification
8.3% 21.8% 76.7%

HF-WBI use rate at HF-WBI use rate HF-WBI use rate
baseline time period after amendment 2 after amendment 3
1) Hypofractionated whole breast irradiation Source: Chapman BV, et al., “Clinical Pathways: A Catalyst for the
2) Conventionally fractionated whole breast irradiation. Adoption of Hypofractionation for Early-Stage Breast Cancer,”
International Journal of Radiation Oncology* Biology* Physics 93.4
©2017 Advisory Board • All Rights Reserved • advisory.com • 34098B (2015): 854-861; Oncology Roundtable interviews and analysis.
Opportunity #2: Implement acuity-based staffing 15
Variation in patient volume, acuity is inevitable

Cancer programs struggle to adjust staffing to match daily fluctuations
Reasons for daily fluctuations Barriers to staffing to meet daily

in patient demand fluctuations in patient demand
Volume fluctuations • Difficult to predict changes in patient demand

• Appointment cancellations • No process in place to monitor changes in
• Add-on patients patient demand and associated staffing needs
• No system in place to measure patient acuity
• Uneven distribution of appointments
throughout the day • No policies for managing cancellations or
add-on patients
Acuity fluctuations
• Complexity of treatment regimen • No process in place to level load the schedule
• Staff unable to come in on short notice
• Adverse reactions to treatment
• No expectation set that staff may be asked not
• Varying length of treatment
to work if there are not enough patients
• Patient comorbidities
• Difficult to predict staff absences
© 2019 Advisory Board • All rights reserved • advisory.com • WF1088267-d 08/13 Source: Oncology Roundtable interviews and analysis.
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Acuity scale stratifies infusions by RN time required

CentraCare Health’s acuity scale for oncology outpatient infusion room
Acuity scale development process

• Map out duration of all regularly
administered treatments and the nurse
time required using evidence-based
guidelines and literature
• Validate nurse time required for
specific treatment regimens by
conducting time studies
• Collect data on patients seen in the
infusion center and their acuity using
the new tool across several months
• Calculate appropriate daily workload
for a single nurse (16 to 24 acuity
points) based on data on patient acuity
collected using the new tool
Source: DeLisle J, “Designing an Acuity Tool for an Ambulatory Oncology

Setting,” Clinical Journal of Oncology Nursing, 13, no. 1 (2009): 45-50;
© 2019 Advisory Board • All rights reserved • advisory.com • WF1088267-d 07/31 CentraCare Health, St. Cloud, MN; Oncology Roundtable interviews and analysis.
CentraCare Health
CASE • Six-hospital system based in St. Cloud, Minnesota
EXAMPLE
► In response to complaints from infusion center nursing staff

about inequitable patient assignments amidst growing
volumes, CentraCare Health assembled a task force to
develop an acuity scale
► Used evidence-based guidelines, literature, and time studies
to develop acuity scale proportional to nurse time required for
specific treatment regimens, then calculated appropriate acuity
points per nurse per day
► Employ three-step process to balance staffing supply and
demand daily; create rough nurse schedule every month,
refine two days in advance based on acuity, assign nurses to
patients on day of treatment
► Managed to accommodate increase in patient volumes without
increasing staff levels, while also decreasing staff overtime
and increasing staff engagement

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Acuity scale stratifies infusions by RN time… (cont.)

19
Tips for developing an acuity-based staffing plan
Key lessons for acuity-based staffing from the Oncology Roundtable
Customize acuity scale Measure nurse time

No one acuity scale can be applied Acuity scales should assign weights or
to all infusion centers; rather, each points to specific procedures based on
infusion center must develop an the amount of nurse time required, not
acuity scale that reflects its patients the duration of the service
and practice patterns
Prioritize objectivity Train staff

For the acuity scale to generate useful To ensure all staff use the acuity scale
data, it must be applied consistently by consistently, they should be trained in
different staff members and over time; its use; managers should conduct audits
consequently, objective criteria are key periodically to ensure the scale is
applied consistently
Related resources available on advisory.com

• Acuity-Based Infusion Center Staffing Tool
• The Three-Step Cancer Staffing Makeover
© 2019 Advisory Board • All rights reserved • advisory.com • WF1088267-d 07/31 Source: Oncology Roundtable interviews and analysis.
20
Helping balance staff supply and demand
Plan
Predict overall staffing needs for upcoming month based on
acuity and volume trends from previous month and communicate
to nurse scheduler
Adjust
Estimate total number of nurses needed each day by pulling
patient schedule two days in advance, totaling acuity points, and
dividing by 16 (minimum workload for one nurse)
Fine tune
Assign individual patients to nurses on the day of treatment to
accommodate last minute changes (e.g., add-ons, cancellations)
Impact of acuity-based staffing model
30% 87% 6%
increase in patient volumes decrease in nurse overtime increase in nurse engagement1
from the year before adoption in the two years following in the three months following
of model to two years after adoption of the model adoption of the model
1) Scheduler, charge nurse, and nursing assistant engagement also increased during this period. Source: DeLisle J, “Designing an Acuity Tool for an Ambulatory Oncology Setting,”
Clinical Journal of Oncology Nursing, 13, no. 1 (2009): 45-50; CentraCare Health,
© 2019 Advisory Board • All rights reserved • advisory.com • WF1088267-d 07/31 St. Cloud, MN; Oncology Roundtable interviews and analysis.
Opportunity #3: Provide proactive symptom management 21
A big problem
ED visits and hospitalizations contribute greatly to avoidable costs
Emergency Department Visits Hospital Admissions
Prevalence Prevalence
56% 63%
Of Medicare patients Of ED visits by Medicare patients
receiving chemotherapy receiving chemotherapy result in
visit the ED each year a hospitalization
Cost Cost
$800 $22K
Average cost for a Average cost for chemotherapy-
chemotherapy-related ED visit related hospitalizations
Source: Fitch K, Pyenson B, “Cancer Patients Receiving Chemotherapy: Opportunity for Better Management,” March
30, 2010, http://us.milliman.com/uploadedFiles/insight/research/health-rr/cancer-patients-receiving-chemotherapy.pdf;
©2019 Advisory Board • All Rights Reserved • advisory.com • 34101C Advisory Board, Data and Analytics Group analysis; Oncology Roundtable interviews and analysis.
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Hardwire support for patients

The Center for Cancer and Blood Disorders maximizes phone triage
Phone Triage at The Center for Cancer and Blood Disorders
Dedicated triage RN advises patient to:

RN receives call • Manage at home
• Come to office
• Go to ED
Patient
experiencing
symptom
Patient calls centralized RN launches symptom
symptom management management pathway in
phone line Navigating Cancer software
• Contains 16 symptom management pathways

• Prompts RN to ask specific questions to determine severity
• Guides RN to document patient response and actions taken
Source: The Center for Cancer and Blood Disorders, Fort Worth, TX;
©2019 Advisory Board • All Rights Reserved • advisory.com • 34101C Navigating Cancer, Seattle, WA; Oncology Roundtable interviews and analysis.
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Hardwire Support for Patients (cont.)
Case in Brief: The Center for Cancer and Blood Disorders

• Community oncology practice with nine locations and 18 oncologists
based in Fort Worth, Texas
• Restructured phone triage system to better manage urgent symptoms
and keep cancer patients out of the ED
• Two RNs dedicated to phone triage, use standardized pathways to
manage 16 common symptoms1
• Partnered with Navigating Cancer to integrate triage pathways into patient
relationship management software platform
• Measured phone triage line call volume, speed of symptom management,
and estimated cost savings from same-day appointments scheduled as a
result of call; estimated that new phone triage system saved them more
than $400,000 in one month
1) Body aches, chest pain, constipation, cycle one follow-up, diarrhea, emergency services,
fatigue, fever and chills, follow-up, nausea and vomiting, nosebleed, oral problems, pain,
respiratory changes, sinus and cold symptoms, transitional care management.
24
Hardwire Support for Patients (cont.)
Technology in Brief: Navigating Cancer

• Patient relationship management software developed by Navigating Cancer, Inc.
headquartered in Seattle, Washington
• Comprised of three components: Care Management (mobile health care tracker, distress
assessments, depression screening and follow-up, pain assessment and care plan),
Population Care (customizable population segmentation, patient use reporting, OCM
reporting, time tracking, insights), and Patient Link (patient education, appointment
schedule, intake and registration, patient portal, meaningful use reporting)
• Symptom management pathways in care management component use branching logic
to provide clinical decision support for triage RNs; institution-specific standing orders at
the end of each pathway empower RNs to work more independently at top of license
Related Resource Oncology Roundtable

For publicly available symptom triage pathways, Related Resource
see COSTaRS’ Remote Symptom Practice Urgent Care for Cancer Patients
Guides for Adults on Cancer Treatments
Source: Stacey D, et al., “Remote Symptom Practice Guides for Adults on Cancer
Treatments,” Ottawa Hospital Research Institute and University of Ottawa,
https://ktcanada.ohri.ca/costars/COSTaRS_Practice_Guides_ENGLISH_March2016.pdf;
©2019 Advisory Board • All Rights Reserved • advisory.com • 34101C Oncology Roundtable interviews and analysis.
25
A measurable impact
The Center for Cancer and Blood Disorder’s Phone Triage Dashboard
One Month of Data
Number of RNs dedicated to phone triage 2
Number of oncologists in practice 18
Number of phone calls managed 1,216
Number of symptom management calls 317

$432,000
Estimated savings per
Number of calls managed immediately 307 (97%) month from preventing
ED visits and subsequent
Number of calls managed without physician intervention 152 (48%) hospitalizations1
Number of calls where same-day appointment scheduled 54
1) Assumed an average cost of $8,000 per ED

visit and potential subsequent hospital charges.
26
Put it in patients’ hands

CCBD1 uses an app to engage patients in symptom monitoring
Health Tracker App
Patient regularly prompted

to input information on:
• Medication compliance
• Symptoms
Triage nurse sees:
• Service utilization outside
of treating institution since • Dashboard with compiled
last appointment patient-reported data
• Prioritized list of patients
to follow up with based
on symptom severity
• Links to relevant
symptom management
pathway for each patient
1) The Center for Cancer and Blood Disorders.

27
Put It in Patients’ Hands (cont.)
Case in Brief: The Center for Cancer and Blood Disorders

• Community oncology practice with 9 locations and 18 oncologists based in
Fort Worth, Texas
• Partnered with Navigating Cancer to use their patient-facing Patient Link platform
component and Health Tracker mobile app for remote monitoring
• Patients receive regular text messages prompting them to complete brief survey on side
effects and oral medication adherence; patients who indicate side effects are asked
follow-up questions to assess severity and whether they would like help from the care team
• Patients with an upcoming appointment are also asked if they have received medical care
for their cancer or other cancer-related issues at another facility, urgent care center, or
hospital since their last appointment in an effort to improve care coordination
• Navigating Cancer software compiles patient-reported data prioritized based on symptom
severity into a dashboard for triage nurses; triage nurses can click on individual patients
to view survey responses and launch the relevant symptom management pathway
• Currently in the process of measuring impact of the Health Tracker app for remote
symptom monitoring
28
Put It in Patients’ Hands (cont.)
Technology in Brief: Navigating Cancer

• Patient relationship management software developed by Navigating Cancer, Inc.
headquartered in Seattle, Washington
• Remote monitoring system allows institutions to customize scheduling of symptom
reporting and oral medication reminders to match any patient’s treatment regimen
• Places certain patients in elevated alert status to trigger more sensitive alerts to the
care team, prompting timely follow-up
29
Successfully decreasing utilization

Memorial Sloan Kettering documents impact of remote monitoring
Study Design: Advanced solid tumor patients receiving chemotherapy were randomized to regularly
report 12 common symptoms using the web-based Symptom Tracking and Reporting (STAR)
platform or to receive usual care consisting of symptom management at the discretion of clinicians
STAR Intervention Results
Percentage of Cancer Patients Percentage of Cancer Patients Percentage of Cancer

Visiting the ED Across One Year Hospitalized Across One Year Patients Alive at One Year
75%
69%
49%
41% 45%
34%
Usual Care STAR Usual Care STAR Usual Care STAR
17% 8% 9%
Decrease Decrease Increase
Source: Basch E, et al., “Symptom Monitoring with Patient-Reported
Outcomes During Routine Cancer Treatment,” Journal of Clinical Oncology,
©2019 Advisory Board • All Rights Reserved • advisory.com • 34101C 34, no. 6 (2016): 557-565; Oncology Roundtable interviews and analysis.
30
Successfully Decreasing Utilization (cont.)
Study in Brief: Symptom Monitoring with Patient-Reported Outcomes

• Randomized control trial of patients receiving routine outpatient chemotherapy
for advanced solid tumors at Memorial Sloan Kettering Cancer Center
• Compared remote patient self-reporting of 12 common symptoms using
web-based STAR platform to usual care consisting of symptom management
at discretion of clinicians; intervention group received weekly email prompts
to report symptoms
• Nurses received email alerts when STAR group patients reported severe
or worsening symptoms; physicians received symptom printouts at visits
• Observed 17% decrease in ED visits at one year, 8% decrease in
hospitalizations at one year, 9% increase in survival at one year, 89% greater
increase in health-related quality of life at six months, and 1.9-month increase
in time on chemotherapy for STAR participants compared to usual care group
Source: Basch E, et al., “Symptom Monitoring with Patient-Reported

Outcomes During Routine Cancer Treatment,” Journal of Clinical Oncology,
©2019 Advisory Board • All Rights Reserved • advisory.com • 34101C 34, no. 6 (2016): 557-565; Oncology Roundtable interviews and analysis.
31
Playbook for Maximizing Oncology Margins
©2019 Advisory Board • All Rights Reserved • advisory.com • 34101C

32
Maximize revenue capture

33
Revenue cycle fraught with challenges
Insurance Coding and

verification documentation
Service Administered to patient
Clinician Payer reimburses

submits Prior Claim …or…
order authorization submission payer denies and
provider appeals
Common Causes of Denial

• Service provided outside of insurance coverage
• No prior authorization
• Insufficient information to illustrate medical necessity
• Incorrect coding and/or documentation
– Wrong drug code
– Wrong diagnosis code for drug
• Denied claim appealed outside appeal period
34
Challenging, but worth the effort

High cost of drugs and increasing denials quickly add up
Ideal Financial Metrics to Track

Infusion Center Revenue Cycle
Results in Brief from an Oncology
Roundtable Member’s Denials Analysis Prior authorization turnaround time
In denials write-offs over

$500K two months due to failure
Bad debt
to get prior authorization Initial denials

for off-label drug use
Denial write-offs
In unreimbursed care
$1M for self-pay patients
Appeal success rate
over one month Cost to collect
Payer mix
©2019 Advisory Board • All Rights Reserved • WF715976-b 08/16 Source: Oncology Roundtable interviews and analysis.
35
Use denials report to highlight gaps in rev cycle

Extracting maximum value from your effort
Patient Drug order Insurance Prior Coding and Reimbursement

registration submission verification authorization documentation or denial
Common Sources of Denials Strategies to Limit Denials
Technical Denials
1 Hardwire monthly insurance eligibility checks
• Registration or eligibility denials
• Failure to obtain prior authorization 2 Hire or designate prior authorization staff
Medical Denials
• Insufficient information to illustrate
3 Make the case for a dedicated oncology coder
medical necessity Launch a clinical documentation

• Off-label use
4 improvement campaign
©2019 Advisory Board • All Rights Reserved • WF715976-b 08/16 Source: Oncology Roundtable interviews and analysis.
36
Communicating results across the team

Avera shares denials with team to keep them top of mind
Avera’s Denials Report
Related Resource
Available on advisory.com
Avera’s Sample
Denials Report
Avera’s Denials Report Information Sharing Process
Denials report Report sent to oncology leaders, who monitor for Oncology clinic managers share
pulled weekly by trends that may signal staffing changes or with financial advocates for
finance office increased communication is needed, or department through one-on-one
emerging difficulties with particular payers or weekly standing meetings
Source: Avera Health, Sioux Falls, SD;

©2019 Advisory Board • All Rights Reserved • WF715976-b 08/16 Oncology Roundtable interviews and analysis.
37
Communicating Results Across the Team (cont.)
Case in Brief: Avera McKennan Hospital & University Health System

• Comprehensive Community Cancer program in Sioux Falls, South Dakota
• Cancer program leader worked for over a year to secure a regular report of infusion
center denials; the main roadblocks to obtaining the report were issues with getting
accurate information from the existing billing software and institutional silos between
the revenue cycle team and cancer institute
• The denials report is sent out every Friday afternoon to department managers; these
managers oversee and relay information to the financial advocates and physicians
• Managers will use these reports in different ways; in medical oncology they have a
standing meeting where the report is a regular agenda item, other department
managers send the report directly to their financial advocates or have one-on-one
meetings; managers ensure follow-up is happening on all open cases
• Finance and oncology leaders monitor denials trending; trends may reflect a need for
financial advocate staffing changes, need for increased communication between the
denials team and financial advocates, or difficulties with certain payers which need to
be addressed by administration
Source: Avera Health, Sioux Falls, SD;

Opportunity #5: Mount a multidisciplinary response to site-of-care pressures 38
Private payers homing in on cost differential

Increase in hospital-based infusions contributing to higher costs
Percentage of Chemotherapy Infusions Cost of Select Infused Drugs to
Delivered in Hospital-Based Setting Private Payers by Site of Care
For Private Payers
Physician Hospital
Brand Name
Office Outpatient
46%
Herceptin $4,131 $7,737
Rituxan $7,328 $11,451
Avastin $2,415 $9,471
Remicade $4,691 $10,995
6% 42%
Increase in costs for infused chemotherapy per
patient per year in hospital-based setting for
2004 2014 private payers compared to physician office
Source: “Cost Drivers of Cancer Care: A Retrospective Analysis of Medicare and Commercially Insured Population Claim Data 2004-2014,”
Milliman, http://www.milliman.com/uploadedFiles/insight/2016/trends-in-cancer-care.pdf; “The Value of Community Oncology: Site of Care
Cost Analysis,” Community Oncology, https://www.communityoncology.org/wp-content/uploads/2017/09/Site-of-Care-Cost-Analysis-White-
Paper_9.25.17.pdf; “Magellan Rx Management Medical Pharmacy Trend Report, Eighth Edition,” Magellan Rx Management,
©2019 Advisory Board • All Rights Reserved • WF715976-b 08/16 https://www1.magellanrx.com/media/722153/tr2017_final_for-website-use.pdf; Oncology Roundtable interviews and analysis.
39
Market forces prompt evaluation of billing status

OhioHealth gathers multidisciplinary task force
OhioHealth’s Market Dynamics
10 Infusion centers
OhioHealth’s Billing Strategy

Infusion centers are provider- Multidisciplinary Task Force
All based, billing under HOPPS • Cancer service line administrators
and care site leadership
• Pharmacy administrators
Infusion centers are 340B
6 covered entities • Legal representatives
• Managed care representatives
• Billing department
Private payers implemented
3 site-of-care policies • Clinical staff (nurses, physicians,
pharmacists)
• Finance team
©2019 Advisory Board • All Rights Reserved • WF715976-b 08/16 Source: OhioHealth, Columbus, OH; Oncology Roundtable interviews and analysis.
40
Market Forces Prompt Evaluation… (cont.)
Case in Brief: OhioHealth

• Multi-hospital, not-for-profit system serving 44 counties based in Columbus, Ohio
• Ten hospital-based outpatient infusion centers, six of which are 340B covered entities
• Impacted by site-of-care policies from three private payers in their market; certain
infused medications could no longer be delivered at infusion centers billing under
HOPPS, and instead would need to be delivered at lower-cost freestanding centers
• Gathered a multidisciplinary team to evaluate site-of-care policies; team created a
clinical algorithm to determine in which cases it would be clinically appropriate to
deliver infusion drugs impacted by site-of-care policies in the freestanding setting
• Used algorithm to negotiate with payers; agreed to charge freestanding rates when
an infusion would be clinically appropriate to deliver in the freestanding setting
• Communicated billing changes to staff and patients and implemented changes to
workflow and prior authorization process to account for new payer negotiations
41
Critically evaluating safety of site-of-care policies

OhioHealth approaches payers after robust analysis
Clinical Algorithm Private-Payer Agreement
Creates algorithm to determine clinical Presents analysis to payers to negotiate

appropriateness of site-of-care policies site-of-care policies
• Considers which infused drugs can safely • OhioHealth infusion centers remain
be delivered in a freestanding clinic HOPDs and bill under HOPPS for
Medicare and Medicaid
• Considers which situations require
infusions to be delivered in a hospital- • OhioHealth reimbursed at freestanding
based outpatient department (e.g., certain rates by private payers for infusions
disease types or patient comorbidities) clinically appropriate to be delivered in a
freestanding clinic
• Provides clinical evidence to support
analysis • Private payers only enforce freestanding
rates only when appropriate as determined
by OhioHealth’s clinical algorithm
42
Laying the groundwork

OhioHealth takes a proactive approach to ensure a smooth transition
Communication Strategy Operational Changes
Staff Update prior

authorization process
Department representatives on
multidisciplinary task force notify Revenue cycle and pharmacy
respective departments of changes departments collaborate to rework
prior authorization process to
include new protocols and identify
Patients when an infusion should be billed
at freestanding rates
Providers notify patients that they
can continue to receive infusions
at OhioHealth, despite notice of
site-of-care policies
Opportunity #6: Invest in comprehensive financial navigation 43
Many patients falling through the cracks

Cancer costs impact access to care, long-term financial health
Common Breakdowns in Patient Access
Program fails to identify Program fails to inform patient Program fails to tap into external
underinsured patient of financial obligation sources of financial support
Program fails to educate patient on Program fails to develop

available assistance programs realistic payment plan
32% 23% 2.65x

Percentage of cancer Percentage of cancer Times more likely
patients reporting patients reporting that they cancer patients are to
cancer-related postponed recommended go bankrupt than
financial problems health care due to cost people without cancer
Source: Kent EE, et al., “Are Survivors Who Report Cancer-Related Financial Problems More Likely to Forgo or Delay Medical Care?” Cancer, 119,
no. 20 (2013): 3710-3717; “A National Poll: Facing Cancer in the Health Care System,” American Cancer Society,
http://acscan.org/ovc_images/file/mediacenter/ACS_CAN_Polling_Report_7.27.10_FINAL.pdf; Ramsey S, et al., “Washington State Cancer Patients Found to
©2019 The Advisory Board Company • advisory.com • 32620A Be at Greater Risk for Bankruptcy Than People Without a Cancer Diagnosis,” Health Affairs, 32, no. 6 (2013): 1-8; Oncology Roundtable interviews and analysis.
44
Most don’t understand basic insurance terms

All patients could use education about their financial responsibility
Americans’ Understanding of Common Health Insurance Terms
By Confidence in the Correct Answer vs. Actual Correct Answer
n=2,000
83%
74%
67%
50% 52%
47%
42% 4%
Of survey respondents
22%
correctly defined all four terms
Deductible Coinsurance Copay Out-of-Pocket

Maximum
Confidence Comprehension
Source: “4 Basic Health Insurance Terms 96% of Americans Don’t Understand,”

PolicyGenius, https://www.policygenius.com/health-insurance/learn/health-
©2019 Advisory Board • All Rights Reserved • WF715976-b 08/16 insurance-literacy-survey/; Oncology Roundtable interviews and analysis.
45
Hardwiring benefit explanation for infusion patients

GBMC uses chemo education as an opportunity
Greater Baltimore Medical Center’s Chemotherapy Education1 Agenda
Nurse Navigator
Financial Counselor
Financial Counselor Name: ______________ Start Time: ________
 Review of individual insurance coverage including copay,
coinsurance, deductibles, out-of-pocket maximums, and
coverage limits
 Does their insurance offer an Oncology Case Manager?
 Place business card in Patient Resource Guide
Support Services
Survivorship
Teach Nurse
For their full agenda, see GBMC’s

1) Almost all infusion patients receive chemotherapy education, New Patient Orientation Checklist
with some exceptions for patients that require an urgent start.
Source: Greater Baltimore Medical Center, Towson, MD;
46
Hardwiring Benefit Explanation for… (cont.)
Case in Brief: Greater Baltimore Medical Center

• Comprehensive Community Cancer program in Towson, Maryland
• All infusion patients, except those who need to start chemotherapy rapidly, attend a
multidisciplinary chemotherapy education session at the cancer center where the patient and
caregiver meet with a social worker, financial counselor, oncology nurse, and lay patient
navigator
• As part of this education, a financial navigator meets with each patient to explain their insurance
benefits, including coverage limits, out-of-pocket maximums, deductibles, copays, and
coinsurance amounts
• In addition to the session with the financial navigator, a nurse navigator discusses his or her
role on the care team and distributes a guide of patient resources; a support services staff
member assesses patient distress, triages patient needs, and makes appropriate referrals; a
member of the survivorship team meets with the patient to introduce the program and discuss
his or her role; lastly, a teach nurse gives patients a tour of the infusion center and explains
what will happen during infusions
• A follow-up visit with support services staff is completed after three cycles of chemotherapy to
check in on patient’s distress, to answer any questions on financial assistance, side effects, and
nutrition; support services staff then coordinate any additional referrals
Source: Greater Baltimore Medical Center, Towson,

©2019 Advisory Board • All Rights Reserved • WF715976-b 08/16 MD; Oncology Roundtable interviews and analysis.
47
Technology adds level of ease to search
How Saint Alphonsus Regional Medical Center Uses Vivor
Vivor continues to search for

assistance funds based on patient
characteristics and alerts financial
navigator if any new funds open
Financial navigator inputs Financial navigator Financial navigator uses

select patient information into contacts patient Vivor to enroll patient
Vivor software Using information from the patient, Patient information saved
Using diagnosis, selected regimen, the financial navigator adds and total assistance
and insurance information, the patient’s household income and provided tracked1
financial navigator does an initial family size to check program
check for patient assistance for all eligibility and give patient overview
infusion patients of available assistance
1) Total assistance provided was tracked manually up until

recently when Vivor released tracking functionality. Source: Saint Alphonsus Regional Medical
Center, Boise, ID; Vivor, New York, NY;
48
Technology Adds Level of Ease to Search (cont.)
Case in Brief: Saint Alphonsus Regional Medical Center

• Comprehensive community cancer program located in Boise, Idaho
• Uses Vivor software as part of financial navigation program; originally, the navigation
program started with one navigator and has grown to ten total financial navigators, who
servce all four cancer programs in the health system
• When a patient starts infusion treatment, the financial navigator initiates the prior
authorization process and leverages Vivor to identify any available external patient
assistance based on patient’s diagnosis and selected treatment plan
• Financial navigator then reaches out to patients, gathers information on household
income and family size, performs a final search, and identifies funds for the patient;
usually enrolls the patient into a patient assistance program within a day
• In fiscal year one, showed $1.1M in pharmacy supply savings and $120,000 in patient
copay assistance; in fiscal year two, Saint Alphonsus set a goal to show $2M in
pharmacy savings and $1M in copay assistance to patients
Source: Saint Alphonsus Regional Medical

49
Technology Adds Level of Ease to Search (cont.)
Technology in Brief: Vivor

• Cloud-based financial assistance platform that allows financial navigators to search
every nationally available manufacturer assistance program and foundation resource
• Vivor allows financial navigation teams to do personalized searches for patient
assistance based off disease and insurance type, sends alerts when funds that active
patients are eligible for re-open, and tracks total assistance provided to patient
• Subscription-based pricing dependent on annual patient caseload; for a cancer
program with 1,000 annual patients Vivor costs $1,000/month and reduced annual bad
debt between $812K to $2.2M1
1) Bad debt reduction based off of Vivor’s customer analysis. Source: Saint Alphonsus Regional Medical
50
Technology proving its worth quickly

Financial navigator time saved, more assistance provided
Benefits of Using Vivor Software
“I remember one morning where I Time it takes, per

got an alert from Vivor that a fund 30 sec patient to look for
had opened up for metastatic customized assistance
prostate cancer. My financial
counselor team quickly searched our
patients and signed three up. Later In patient copay
that afternoon, when I checked back, $120K assistance collected for
the fund was closed!” patients in the first year
Melanie Woodland
Financial Resource Manager, Saint Alphonsus
$1.2M In pharmacy savings

attributed to drug
replacement programs
found by navigators
using Vivor1,2
1) Pharmacy savings tracked manually by the financial navigation team.
Tracking functionality within Vivor software was rolled out in early 2018.
2) For a cancer program with 1,000 annual patients Vivor costs
$1,000/month. Vivor estimates users will see an annual bad debt
between $812K to $2.2M.
Source: Saint Alphonsus Regional Medical
51
©2019 Advisory Board • All Rights Reserved • WF715976-b 08/16

52
Prioritize profitable growth

53
Competition not slowing down

Majority of markets report increasing competition for cancer services
Over the past 24 months, how has the level of

competition in your market changed?
n=235 cancer program leaders
Stayed the Slightly

Same Increased
39%
33%
32% of academic cancer

centers report that
competition in their market
Not Sure 4% 19% has significantly increased
2% over the past 24 months
Significantly Significantly
Decreased 3%
Increased
Slightly
Decreased
Source: 2018 Trending Now in Cancer Care Survey;

©2019 Advisory Board • All Rights Reserved • WF715976-c 11/13 Oncology Roundtable interviews and analysis.
54
Meeting your customers’ unique needs

Critical to tailor cancer program strategy to each audience
Questions to Ask About Three Main Customers
Referring Physicians Self-Directed Patients Employers

• Which of our cancer center’s • What information are • Does our organization currently
strengths aligns best with current and prospective have any relationships with local
referring providers’ patients looking for online? or national employers?
preferences?
• How effective are our • Which cancer screening or
• How well do we understand direct-to-patient marketing prevention programs would
our referral patterns and campaigns? make the most sense to offer to
leakage? • Do we have a strategy to different employers?
• What do referring providers in manage and share patient • What other value-add services
our market care about most? reviews online? would benefit employers and
employees?
• How many steps does it take • What is the biggest
to refer patients into our dis-satisfier for our • Is there a potential for direct-
program? patients? to-employer contracting in our
market?
©2019 Advisory Board • All Rights Reserved • WF715976-c 11/13 Source: Oncology Roundtable interviews and analysis.
Opportunity #7: Formalize referring physician partnerships 55
Oncology still a referrals-driven business

But market forces are changing referring providers’ behavior
Typical Referral Path
Primary Care
Patient Specialist Proceduralist Hospital
Physician
Two Market Forces Changing Referring Provider Behavior
1 Continued M&A 2 Increased Provider Risk

• Hospital and physician consolidation • Physicians increasingly accountable
continues as fee-for-service reimbursement for cost and quality under MACRA1
declines and incentives to integrate grow and other risk-based payment models
• Hospitals aim to keep acquired physicians’ • Physicians incentivized to refer patients
referrals within the system to high-quality, low-cost providers
1) Medicare Access and CHIP Reauthorization Act of 2015
©2019 Advisory Board • All Rights Reserved • WF715976-c 11/13 Source: Oncology Roundtable interviews and analysis.
56
Putting the pieces together
Key Elements of Fox Chase Cancer Center’s (FCCC) Care Connect Program
1 Two-Sided Value Proposition

Stakeholders from FCCC and Temple
Community Physicians, Inc. met to design a
mutually beneficial program
1 2 2 Targeted Education
Participating practices are required to
participate in physician and staff education
3 Cohesive Marketing
3 4 Participating practices and FCCC share new
branding and marketing collateral
4 Physician Alignment
Participating practices and FCCC build strong
relationships that lead to confident referrals
Source: Fox Chase Cancer Center, Philadelphia, PA;

57
Putting the Pieces Together (cont.)
Case in Brief: Fox Chase Cancer Center

• 100-bed hospital in Philadelphia, Pennsylvania
• NCI-designated Comprehensive Cancer Center
• Fox Chase Cancer Center (FCCC) recognized the existence of gaps in care
coordination between the cancer center and referring primary care physicians
• FCCC established a stakeholder group with representatives from FCCC and
Temple Physicians, Inc., a community-based physician network, to establish the
Care Connect program, a framework for engaging PCPs
• Care Connect requires participating PCPs to attend two education events per year,
preferably in person, though a virtual option is available; FCCC creates and teaches
this curriculum; additionally, FCCC staff hold lunch-and-learn sessions for Care
Connect PCP’s office staff
• FCCC provides comprehensive branding for all participating PCPs that includes a
framed certificate, brand guidelines, brochures for patients, and templated press
releases

Element 1: Two-Sided Value Proposition 58
Understanding what each side wants

Aligning goals creates foundation for success
Value Proposition of the Fox Chase Cancer Center Care Connect Program
Referring Providers1 Fox Chase Cancer Center
• Access and communicate with FCCC • Improves process for transition to

survivorship
• Improve QPM2 scoring
• Build brand identification • Provides screening, risk, and
diagnostic services
• Receive education on cancer
• Strengthens relationships with
prevention, screening guidelines,
referring providers
and survivorship
1) Both employed Temple physicians and independent physicians.

2) Quality Physician Measure scoring, a requirement of one of the main
insurers in Philadelphia.
Element 2: Targeted Education 59
Targeted education brings results
Educational Components for Care

Connect Practices
In-Person Physician Events
• Care Connect physicians required to attend two
education events per year
80%
Of physicians who attended
– Training sessions led by both Care Connect educational events reported
PCPs and FCCC physicians changes in their clinical practice
• Virtual options available
• Sample topics include survivorship issues, lung
cancer screening, and geriatric oncology
Lunch-and-Learn Sessions for Office Staff
• 30-minute content sessions on topics such as the
basics of clinical trials taught by Fox Chase Care 23%
Connect team Increase in correct responses from
Email Communication office staff on test of colorectal
• Educational email blasts on topics such as the screening guidelines after targeted
Cancer Moonshot or breast cancer screening lunch-and-learn sessions
guidelines

Element 3: Cohesive Marketing 60
Multipronged marketing creates cohesive brand

For PCPs and cancer providers
Care Connect Physician Marketing Cancer Center Marketing
Care Connect logo and Dedicated Care Connect website

branding guidelines
Brochures for Alerts in Fox Chase’s daily email

patients update when new practices join
Care Connect
Templated press Posters in key work areas such

releases as the clinic space and patient
waiting areas
Presentations during walking

Framed certificate
rounds of inpatient units and
of membership
department meetings

Element 4: Physician Alignment 61
Provide tangible benefits to PCPs

PCPs improve engagement with oncologists
Care Connect’s Physician Alignment Process

Overall Results of Care
Connect Program
Care Connect PCPs feel confident
recommending patients to FCCC
16 days
From PCP appointment
request to PCP
appointment day1
22%
Increase in referrals to Fox
Patients entering survivorship with Chase Cancer Center
no designated PCP recommended to
Care Connect PCPs
1) Five days faster than the regional average.

Opportunity #8: Implement a strategy to manage patient reviews 62
Many patients go online for health information
Increase in adults Of all internet users

320% 65 and older who
use the internet,
72% looked online for
health information
from 2000-2016
Of cancer patients Of cancer patients

48% used online
resources when
25% researched providers
online for over one
selecting a provider hour (more than any
other specialty
population)
Source: Market Innovation Center, Advisory Board; Oncology

©2019 Advisory Board • All Rights Reserved • WF715976-c 11/13 Roundtable interviews and analysis.
63
No shortage of feedback channels

Negative reviews can have a disproportionate impact
For Patients, Low-Investment Recourse

Consumers 52%
“It could be argued these sites have proliferated
more likely to
by being an alternative to costly and frustrating
share a negative
malpractice suits…. The price of posting a
experience over a
negative review over frustrations with attitude,
positive experience
billing, or a diagnosis? Zero.”
on Yelp
BuzzFeed
Consumers 50%
more likely to
For Providers, Lasting Damage
share a negative “From now until the end of time, I’ll be the jerk
experience over a neurologist who was rude to a World War II
positive experience veteran. I’m stuck with it forever.”
on social media
David McKee, MD, whose reputation
suffered after a patient’s son posted
multiple negative online reviews
Source: Rossen J, "Insult and Injury: How Doctors Are Losing the War Against Trolls," BuzzFeed
http://www.buzzfeed.com/jakerossen/insult-and-injury-inside-the-webs-one-sided-war-on-doctors; “Bad Customer Service Interactions More
Likely to Be Shared Than Good Ones,” Marketing Charts, https://www.marketingcharts.com/digital-28628; Physician Practice Roundtable,
©2019 Advisory Board • All Rights Reserved • WF715976-c 11/13 Building the Service-Driven Medical Group, Washington, DC: Advisory Board, 2014; Oncology Roundtable interviews and analysis.
64
Competing with Google

University of Utah publishes all patient reviews online
John Doe1
Dr. Doe
1) Pseudonym Source: University of Utah, Salt Lake City, UT; Physician Practice
Roundtable, Building the Service-Driven Medical Group, Washington, DC:
©2019 Advisory Board • All Rights Reserved • WF715976-c 11/13 Advisory Board, 2014; Oncology Roundtable interviews and analysis.
65
Promote Full Transparency (cont.)
Case in Brief: University of Utah Health Care

• Academic medical center based in Salt Lake City, Utah, employing 1,200
faculty physicians
• In 2013, became the first major hospital to post providers’ individual patient
satisfaction scores and comments online
• Strategy rolled out after leaders noted that social media reviews skewed more
negative than actual survey feedback
• Profile development process took approximately six months; compared survey
scores to social media rankings to verify the benefit of full transparency and
allowed provider input three months prior to launch
Source: University of Utah, Salt Lake City, UT; Physician Practice

66
A thoughtful approach to profile design

University of Utah’s Process to Publicize Physician Data
Gathered Data Curated Content Streamlined Design Managed Reactions
• Compiled existing • Identified necessary • Created profiles1 • Showed physicians

reviews on all content for profile to previews of their
• Edited appearance
major physician be useful, credible profiles three
to be consistent with
rating sites • Decided to include: months before
typical rating sites
public launch
• Compared social – Ten provider (e.g., five-star
media ratings with communication rating system) • Met with physicians
survey scores to metrics, wait times • Tested webpage to discuss concerns2
ensure advantage of usability
publishing scores –Both positive and
negative comments
Of patient comments posted in

99% their entirety3
Source: University of Utah, Salt Lake City, UT;
1) Resources loaned for start-up involved enterprise data warehouse architect, Social Content Office director and analyst, patient experience director and analyst. Physician Practice Roundtable, Building the Service-
2) Allow physicians to flag comments for review by system physician committee on a case-by-case basis. Driven Medical Group, Washington, DC: Advisory
3) 1 FTE data analyst monitors comments, in addition to other responsibilities; comments filtered only for personal attacks, inappropriate (e.g., racist) remarks. Board, 2014; Oncology Roundtable interviews and
©2019 Advisory Board • All Rights Reserved • WF715976-c 11/13 analysis.
67
Transparent data draws patient attention

Also helps motivate clinical providers
Yearly Physician Profile Views Percentage of Hospital-Employed

Before and After Patient Reviews Physicians Achieving Top Scores
Posted Online Compared to National Cohort
128% increase
1,148,720 50%
25%
503,070
9%
3%
Year prior to Year after Top 10% Top 1%

posting patient posting patient
reviews reviews Year 0 Year 1
Source: University of Utah, Salt Lake City, UT; Physician Practice

Opportunity #9: Build meaningful employer partnerships 68
A major burden for employers

Cancer accounts for 12% of employer costs
53% $264B 47%

Total cost of cancer care for US
employers in 2015
Direct Costs Indirect Costs

• Treatment costs • Short- and long-term
• Prescription and disability leave
medical drugs • Decreased workplace
• Additional medical productivity
services • Additional hires
• Premature retirement
Source: Nobel J, et al., “Cancer and the Workplace: The Employer Perspective,” Northeast Business
Group on Health, http://nebgh.org/wp-content/uploads/2015/10/CancerWorkplace_FINAL.pdf;
69
Understand your market

Moffitt performs comprehensive analysis of employers
Six Sources of Information
1 Billing data: Identify employers of patients they serve

and which health plans these employers use
2 Tampa Bay Business Journal and Chamber of

Commerce: Collect data on local business and
networking organizations
Existing community partners: Leverage existing

3 relationships with employers in the market
Strategy and planning departments: Understand

4 current employer relationships at Moffitt
Marketing department: Understand brand awareness

5 and top priorities
One-on-one employer interviews: Assess employers’

6 priorities across range of sizes and industries
Source: Moffitt Cancer Center, Tampa, FL;

70
Understand Your Market (cont.)
Case in Brief: Moffitt Cancer Center

• NCI-designated Comprehensive Cancer Center with three locations in the greater
Tampa, Florida, area
• 56,258 patients seen in 2016 according to Moffitt’s 2016 Annual Report
• To meet their goal of developing employer partnerships, Moffitt performed a market analysis
to gain a better understanding of the top employers in their market and their priorities; in
addition, they evaluated which services currently offered at Moffitt would be scalable to offer
to other employers
• Before launching any partnerships, Moffitt hosted an employer forum to build relationships
with employers in their market, provide education around cancer care, and solicit employer
feedback on opportunities to partner
• Based on Moffitt’s current offerings and employer interest, their goal is to launch a
partnership product to employers in their market; in exchange, employers would allow Moffitt
to provide education to their employees and keep Moffitt as an in-network provider on their
insurance plans
• Moffitt hopes that these partnerships will continue to evolve and grow with the potential for
employers to purchase additional services or formalize Moffitt as a center of excellence

71
Determine which services to offer

Perform an internal assessment to identify scalable, high-value services
Sample Services Offered at Moffitt Key Questions
Navigation • Is this service scalable?

• What additional investments would be
required?
Precision medicine
• What are the benefits of this service to
employees?
Screening and prevention • Would employers value this service?
• Do our competitors offer this service to
Second opinions employers?
• Do we have buy-in from executives to
expand this offering?
Bundled payment models
Moffitt developed a robust case to gain

Related resources available on C-suite support to allow their employer
advisory.com strategy to have a lasting impact
The Oncology Leader’s Guide to
Developing Employer Partnerships

72
Getting to know you

Moffitt hosts employer forum to provide education and build relationships
35 attendees from
30 local companies
Sample Employer Educational Sessions
Difficulties of Patient testimonials Difference between Importance of Cancer screening

working throughout on cost and impact genetic and patient reported and prevention
cancer treatment of cancer diagnosis genomic testing outcomes
Moffitt’s Calls to Consider the impact Ensure health plans allow Provide feedback on
Action for Employers of cancer care on your for genomic testing, how Moffitt can best
working employees second opinions, etc. support your workforce

73
Ensure interests are aligned

Moffitt solicits feedback from employers before launching products
Moffitt Outlines Potential Areas to Partner
Provide cancer screening

services and education
to employees
Provide education to benefits

professionals and insurers on
7
importance of genomic testing Number of employers who
second opinions, etc. contacted Moffitt within a week of
the forum interested in partnering
Provide Moffitt navigation
services to employees
Moffitt plans to develop an employer

Provide employees opportunities partnership product based on this feedback
to enroll in clinical trials on patient
reported outcomes at Moffitt
Provide employers opportunities to

participate in payment models
(e.g. bundles for certain tumor types)

74
©2019 Advisory Board • All Rights Reserved • WF715976-c 11/13

75
Road Map
1 A Margin Problem

76
Moving the mark on margin management

Narrowing our focus to three priorities
1 2 3
Control Maximize revenue Prioritize profitable
costs capture growth
1. Reduce unwarranted 4. Use financial reporting 7. Formalize referring

care variation to diagnose gaps physician partnerships
2. Implement acuity- 5. Mount a multidisciplinary 8. Implement a strategy to
based staffing response to site-of-care manage patient reviews
3. Provide proactive pressures 9. Build meaningful
symptom management 6. Invest in comprehensive employer relationships
financial navigation
Find more strategies at https://www.advisory.com/research/oncology-

roundtable/resources/2019/playbook-for-maximizing-oncology-margins
2019 Oncology Roundtable National Meeting Series
Meeting Agenda Speakers
Oncology State of the Union Cancer Patient Experience Survey Workshop
• Reimbursement and regulatory changes impacting (optional)
oncology Oncology Roundtable experts will show you how to
• Proposed alternative payment models and lessons slice and dice data from our Cancer Patient Experience
learned from the Oncology Care Model Survey, allowing you to analyze patient preferences by
• Targeted drugs and immunotherapies multiple factors, such as tumor site and age
What Matters Most to Cancer Patients How to Survive-and Thrive-in a System

• Surprising findings from our 2019 Cancer Patient • Guidance on managing political dynamics and working
Experience Survey effectively with system and site leaders
• How patients make trade-offs when choosing providers, • Frameworks for making principled decisions for Stuart Clark
and how you should allocate resources investment and delivery of services Senior Director
• Where programs are most vulnerable to patient leakage, • Tactics to align strategy and care delivery across sites The Advisory Board
and how to reduce your risk • Strategies for helping your team maintain morale and
adapt to new ways of working
Speed Networking Reception
Attendees will have the opportunity to reconnect with Build an Engaged Oncology Workforce
colleagues, make new contacts, and share best practices • Innovative strategies to drive engagement and reduce
in real time. Participants will select a discussion topic of turnover for key team members
their choice, such as survivorship or oncology payment • Lessons to develop data-driven staffing models
reform, for this high-value networking session. • Applications of newly updated benchmark generators
Chicago, IL Philadelphia, PA
July 16-17 August 26-27
Carol Boston-Fleischhauer
Dana Point, CA Managing Director
Washington, DC
August 12-13 The Advisory Board
May 13-14
September 12-13
Virtual Broadcast Atlanta, GA

July 31-August 1 July 1-2
©2018 Advisory Board • All Rights Reserved 77 advisory.com

78
Thank you!
Feel free to reach out with questions:
sauletd@advisory.com
202-568-7863
©2016 The Advisory Board Company • advisory.com

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Oncology Roundtable

2 Three Priorities for Cancer Programs

3 Prioritizing for Your Program

©2016 The Advisory Board Company • advisory.com • 32620A

A poster child for high costs

The Wall “Insurers Push to Rein in

Drug costs on everyone’s radar

Exacerbated by rising demand

Estimated number of new cancer Factors driving increased cancer volumes

Forcing purchasers to double down on spend

Three areas of focus for payers and employers to control costs

Treatment costs Site of care Provider choice

The margin problem

Moving the mark on margin management

1. Reduce unwarranted 4. Use financial reporting 7. Formalize referring

2 Three Priorities for Cancer Programs

3 Prioritizing for Your Program

©2016 The Advisory Board Company • advisory.com • 32620A

©2019 The Advisory Board Company • advisory.com • 32620A

Realizing the importance of care standardization

Clinical standardization 54%

Care coordination (e.g., navigation) 41%

Non-clinical staff 39%

Technology maintenance 13%

Capital expenses (e.g., LINAC, imaging tech) 11%

Patient wellness (e.g., yoga, nutrition) 4%

Source: 2018 Trending Now in Cancer Care Survey;

Despite benefits, uptake of pathways still limited

Demonstrating the Cost Savings

Value Pathways² and Aetna Pilot

Taking a homegrown approach

Overview of Clinical Pathways Development at Dana-Farber

Discussed importance Partnered with Via Implemented

Year 1 Year 2 Year 3 $17,085

Proposal for radiation APM just released

Changing practice step by step

Major Milestones in Breast Clinical Pathway Development at UPMC

January Year 1 Amendment 1 January Year 2 Amendment 2 January Year 3 Amendment 3

8.3% 21.8% 76.7%

Variation in patient volume, acuity is inevitable

Reasons for daily fluctuations Barriers to staffing to meet daily

Volume fluctuations • Difficult to predict changes in patient demand

Acuity scale stratifies infusions by RN time required

Acuity scale development process

Source: DeLisle J, “Designing an Acuity Tool for an Ambulatory Oncology

► In response to complaints from infusion center nursing staff

Source: DeLisle J, “Designing an Acuity Tool for an Ambulatory Oncology

Acuity scale stratifies infusions by RN time… (cont.)

Source: DeLisle J, “Designing an Acuity Tool for an Ambulatory Oncology

Tips for developing an acuity-based staffing plan

Key lessons for acuity-based staffing from the Oncology Roundtable

Customize acuity scale Measure nurse time

Prioritize objectivity Train staff

Related resources available on advisory.com

Helping balance staff supply and demand

Impact of acuity-based staffing model

Emergency Department Visits Hospital Admissions

Hardwire support for patients

Phone Triage at The Center for Cancer and Blood Disorders

Dedicated triage RN advises patient to:

• Contains 16 symptom management pathways

Hardwire Support for Patients (cont.)