6562 Background: US cancer costs are projected to increase to over $173 billion in 2020. Clinical pathways can help curb rising costs by reducing unnecessary and costly treatment variation while improving pt outcomes. Initial treatment may have the greatest pathway impact as it influences pt outcomes and subsequent care. We evaluated cost savings of a payer-sponsored pathway program for pts with cancer receiving first chemo intervention. Methods: A large payer for the Mid-Atlantic region of the US collaborated with its community oncology provider network to create a 3-year pathway program, managed by Cardinal Health, for chemo-naïve pts. Using claims data, 3 years of chemo and supportive care drug use were evaluated to establish a baseline cost trend for pts with breast cancer (BC), colorectal cancer (CRC), and lung cancer. Using this baseline as historical control, pts who started first-line treatment in pathway year 1 were included in the analysis. All drug costs were standardized to average sales price effective in the last quarter of the program year. Although voluntary, participating physicians received financial incentives for additional work required to manage the program. Results: The pathway cohort consisted of 453 pts; historic control cohorts for years 1-3 consisted of 362, 325, and 387 pts, respectively. Arms were well balanced; 24% were diagnosed with CRC in the study arm vs 26% in the control arm; 45% vs 44% for BC, and 31% vs 30% for lung cancer, respectively. Savings relative to projected cost/pt/year for pathway cohorts were $21,106 for CRC and $2,964 for lung cancer. For BC, cost increased $9,271. Overall mean cost/pt, adjusted for trastuzumab use (29% study vs 21% control), decreased 5% ($1,698 pt/yr) for an aggregate savings of $750,436. Conclusions: Voluntary pathway participation can lower drug cost of common malignancies even in first-line treatment. The approach of limiting pathway inclusion to chemo-naive pts will provide the greatest clarity of pathway impact throughout the duration of illness. This is our third report of reduced cancer care cost despite enhanced physician reimbursement. We believe the body of evidence dispels concerns about reproducibility of pathways benefits.

e17538 Background: Clinical pathways can change practice patterns that result in benefits for all stakeholders; however, their impact on other regional payers is unknown. Will a first-to-market pathway serve as a rising tide that benefits all regional payers or result in higher resource utilization for other payers? Aetna and Cardinal Health implemented an oncology pathway in which the dominant regional commercial payer had previously implemented a similar pathway program. We assessed cost of care associated with this second-to-market oncology pathway. Methods: Using claims data for the baseline and first operational years of the pathway (7/1/2010- 6/30/2012), we compared chemotherapy, supportive care, emergency room (ER) and hospital admission costs for patients (pts) with breast, lung, and colorectal cancer treated by providers voluntarily participating in the pathway program with pts treated by nonparticipating providers. Savings were determined by comparing year-over-year cancer-related drug and hospital costs/pt for the study and control groups. Costs were calculated according to the Aetna Market Fee Schedule. Results: Pt cohorts were adjusted for variations in tumor type and age using the distribution for the operational year study group (n=51) as a baseline. In the operational year, cost/pt for chemotherapy and supportive care drugs decreased by 18.3% among participating providers and increased by 3.8% among nonparticipating providers. The average number of ER admissions decreased by 0.8% among participating providers and increased by 8.5% among nonparticipating providers. Inpatient days/pt decreased in both groups; however, inpatient days/pt were significantly higher for the control arm in the baseline year. The difference in the drug-cost trend between participating and nonparticipating providers was 22% resulting in a savings of $7,037/pt/year. The aggregated savings for drug costs and ER admissions was $7,402/pt/year. Conclusions: These results suggest that collaborative pathway programs can be successful in improving evidence-based care and lowering costs, even when implemented by payers with low market penetration and in markets in which providers are actively participating in another payer-sponsored pathway program.

e17542 Background: The unsustainable cost curve of cancer care has been the focus of much debate. Pathway programs have been suggested as a means to decrease treatment variability, thereby making cost more predictable and improving quality of care. Integration of pathways into electronic medical records (EMR) has been considered critical to adoption and influence, but myriad health information technology platforms make this problematic. Web-based non-EMR-integrated decision support tools (DST) represent an alternative, but workflow redundancy is a concern for adoption. We report initial experience with the adoption of a pathway program that incorporated a DST and the impact of the DST on pathway compliance. Methods: Medical oncologists participating in a large regional insurance network in the Southeastern region of the United States signed voluntary participation amendments for a pathway program managed by Cardinal Health that encouraged use of a web-based DST (Pathware). Enhanced reimbursement was offered to mitigate increased workflow requirements. Payer claims data was applied to a treatment algorithm to identify regimens administered, which was then matched to the patient regimen inventory created within the DST. Results: A total of 24 physicians from 10 practices agreed to participate in year 1 of the pathway; an additional 14 physicians from 5 practices signed participation agreements during the course of the year. Claims data revealed 311 treatment regimens for the 24 physicians who completed a full year in the program. Of these, 111 (36%) could be matched to a DST selection. An additional 109 regimen selections were found in DST for patients not found in network claims data. Of the entire 420 chemotherapy regimens identified, compliance to the pathway was consistently higher with regimen selection using the DST than with those found only in claims, 91% vs 84%, respectively. DST adoption rates were disparate among providers and ranged from 0% to 100%, with a mean of 48%. Conclusions: Non-EMR integrated web-based DSTs can be successfully deployed across disparate provider networks to facilitate pathway program compliance. Barriers to adoption need to be identified and overcome as DST use has favorable impact on compliance.

OBJECTIVES:In partnership with a large nonprofit healthcare insurer for the Mid-Atlantic region of the United States, we launched the first cancer clinical pathway in the United States in August 2008. Due to its early success with regard to savings and physician participation and compliance, a second-generation pathways program-the Oncology Medical Home-was piloted in 2011. This program offered a physician reimbursement model that shifted the source of revenue from drug reimbursement margin to professional charges for cognitive services (evaluation and management codes). We report our observations of the impact of that reimbursement model on physician prescribing behavior.STUDY DESIGN:This was a retrospective analysis.METHODS:A select group of practices that participated in the first-generation pathways program were invited to voluntarily participate in the Oncology Medical Home and its cognitive weighted reimbursement design. A matched control group was chosen from the first-generation pathways participants. Comparisons of physician behavior parameters were made pre- and postimplementation and between the Oncology Medical Home practices and the first-generation pathways control group.RESULTS:Physician behavior was not significantly modified by cognitive weighted reimbursement. No significant change in frequency of office visits for established patients was observed. No change in chemotherapy prescribing was observed. Observed increases in generic regimen use were no different than matched control.CONCLUSIONS:Observations from this oncology medical home pilot program suggest that reimbursement methodology alternatives to the prevailing fee-for-service may have less impact on prescribing behavior than has been conjectured. Future research is ongoing to validate these observations and assess additional influences on prescribing behavior.

e17581 Background: CareFirst BlueCross BlueShield (CFBCBS) partnered with Cardinal Health Specialty Solutions (CHSS) to launch the first cancer care clinical pathway in the United States in August 2008. Due to early success of the program with regard to savings and physician participation and compliance, CFBCBS and CHSS piloted an oncology medical home program in January 2011 with the hope of further decreasing cancer care costs while continuing consistency and quality of patient care. The medical home program offered a new physician reimbursement model that shifted the source of revenue from margin on drug sales to cognitive services. This would allow physicians to focus on optimal patient care without the financial incentive to prescribe chemotherapy. We analyzed the financial impact of the medical home program on participating physicians 1 year after implementation. Methods: Intravenous drug codes plus the evaluation and management codes for patient visits and chemotherapy administration were used in the analysis. We analyzed amounts paid to participating practices for chemotherapy, supportive care treatments, and nondrug services for year +1 to the amounts paid for the same services for year -1. We also analyzed the medical home fee schedule for year +1 when compared to the first-generation fee schedule applied to program year +1 utilization. This was calculated by repricing year +1 claims to the first-generation fee schedule and comparing that cost to what was actually paid under the medical home fee schedule. Results: Fourteen practices (31 physicians, 478 patients) joined the medical home program. Average amounts paid to physicians were 4.7% higher for year +1 compared to the prior year. The average cost difference for year +1 based on the medical home fee schedule versus the first-generation fee schedule was -5.7%. If physicians had chosen not to join the medical home program their revenues would have increased by 11%. Conclusions: Drug cost inflation was a significant contribution to savings in this model and directly impacts the observed lower average reimbursement to medical home participants versus their pathway program peers. Providers are likely to seek remedies for continued participation.

6629 Background: Extensive literature has cited fee-for-service physician reimbursement methodology as a critical driver of resource utilization constituting overtesting, overtreatment, and an impediment to bending the cost curve in cancer care. CareFirst BlueCross BlueShield (CFBCBS) partnered with Cardinal Health Specialty Solutions to launch the first cancer clinical pathway in the US in Aug 2008. Physician participation was voluntary and reimbursement remained fee-for-service. Due to its early success with regard to savings and physician participation and compliance, an oncology medical home (MH) program was piloted in Jan 2011 offering a new physician reimbursement model, which shifted the source of revenue from margin on drug sales to cognitive services. This would allow physicians to focus on optimal patient (pt) care without the financial incentive to prescribe chemotherapy (chemo). We analyzed physician behavior modification after this change in reimbursement structure 1 year after implementation...

e17579 Background: CareFirst BlueCross BlueShield (CFBCBS) partnered with Cardinal Health Specialty Solutions (CHSS) to launch the first cancer care clinical pathway in the United States in August 2008. Due to the early success of the program with regard to savings and physician participation and compliance, CFBCBS and CHSS piloted an oncology medical home program in January 2011 as an attempt to further decrease cancer care costs. The medical home program encouraged physician commitment to an intensive CQI program. We analyzed the potential savings of this program over 1 year. Methods: Data were collected from April 2011 to May 2012. The CQI measurements were obtained from a monthly online survey, completed by medical home participating practices, regarding patient (pt) accrual, clinical profiles, treatment regimens, adverse events, clinical outcomes, and end-of-life care. Two components of the CQI program were analyzed: (1) a 24-48 hour post-treatment follow-up contact by nurses triggered by the initial visit for chemotherapy, and (2) an end-of-life initiative comprised of queries to identify patterns of care in the final days of pts with terminal cancer. Results: Fourteen practices (31 physicians, 478 pts) joined the medical home program. Of the 51 pts who received cycle 1 day 1 of chemotherapy, 38 (75%) were contacted by a nurse within 24-48 hours. Clinical interventions were made for 15 of 38 pts (39%); 5 (13%) involved a return to the clinic. Fifteen pt deaths occurred in year 1. Five (42%) of these pts were in hospice for 0-7 days prior to death, 2 (17%) for 8-14 days, and 4 (33%) for 15+ days. Twelve (80%) of these pts received hospice referral. One pt (6.5%) received chemotherapy within 14 days of death. Seven pts were hospitalized within 14 days of death, and 3 (20%) pts died in the hospital. Conclusions: The nurse follow-up program resulted in prevention of no less than 5 and as many as 15 emergency room visits, and 3-10 related hospitalizations were likely prevented by this intervention. A CQI program can positively impact savings through presumed reductions in emergency room and hospital admissions. Combining these reductions with an end-of-life care initiative represents a great opportunity for cost savings.

e17582 Background: CareFirst BlueCross BlueShield (CFBCBS) partnered with Cardinal Health Specialty Solutions (CHSS) to launch the first cancer clinical pathway in the United States in August 2008. Due to the early success of the program with regard to savings and physician participation and compliance, CFBCBS and CHSS piloted an oncology medical home program in January 2011 with the hope of further decreasing cancer care costs while continuing consistency and quality of care. We analyzed payer ROI after year +1 of the medical home program. Methods: The medical home program offered a new physician reimbursement model that shifted the source of revenue from margin on drug sales to cognitive services allowing physicians to focus on optimal patient care without the financial incentive to prescribe chemotherapy. Physicians were encouraged to commit to an intensive continuous quality improvement (CQI) program, which included an end-of-life initiative and a post chemotherapy nurse call-back program that would lower costs by decreasing emergency room and hospital admissions. Physicians participating in the first CFBCBS pathway program were eligible to join the medical home program; physicians who chose not to join made up the control group. Data were collected from April 2010 to March 2012. Medical home ROI was calculated by subtracting the total weighted cost per patient for the medical home group from the total risk-adjusted cost per patient for the control group multiplied by the total number of patients in the medical home program. Results: Fourteen practices (31 physicians, 478 patients) joined the medical home program. The control group was comprised of 39 practices (103 physicians, 2031 patients). Total weighted cost per patient for the medical home program for year +1 was $26,702. Risk-adjusted cost per patient for the control group for year +1 was $30,670. The medical home program provided a gross savings of $2,016,868 compared to the first CFBCBS pathways program. Conclusions: Significant savings can be achieved in a provider group already compliant with a mature pathways program. A CQI program can directly and favorably impact patient outcomes and ROI via presumed reduction in emergency room and hospital admissions.

e16540 Background: CareFirst BlueCross BlueShield (CFBCBS) partnered with Cardinal Health Specialty Solutions (CHSS) to launch the first cancer care clinical pathway in the US in Aug 2008. CFBCBS, CHSS, and members of the provider network sought to create a unique mechanism of reimb for network phys as part of the pathways 2nd-generation program. Fee schedules for IV medications (meds) were reduced, and fee schedules for evaluation and management (EM) codes were increased, so that on an aggregate, weighted basis there was no expected change in overall phys reimb. This would allow phys focus on optimal treatment course without the financial incentive to prescribe chemotherapy (CT). We analyzed the impact of this novel reimb model on phys revenue after 1 year (yr). Methods: Thirty-one CFBCBS network medical oncologists comprising 14 practices volunteered to participate in the pilot program. Using the 2009 benchmark yr, all IV CT J codes, administration (admin) codes, and EM codes were analyzed. Phys were then being paid above Medicare allowable for IV meds. The design of the pilot program was to shift payment for IV meds to Medicare allowable and move the extra dollars to enhance EM codes. This process was prorated more heavily weighted towards the new pt codes. Phys were also offered the option of having meds white bagged through a specialty pharmacy. The same codes from 6 mo of 2011, the yr the plan was instituted, were collected and extrapolated to reflect 12 mo of program experience and compared to pre-program data from 2009. Results: In 2009, phys generated 25,282 J codes, 24,950 EM codes, and 19,340 admin codes. In 2011, they generated 22,288 J codes, 23,040 EM codes, and 15,634 admin codes. The net impact on phys revenue in 2011 was -1.5% (range +2% to -4%) compared to 2009. None of the practices selected the white bag specialty option. Conclusions: This data demonstrates that a reimb model that shifts the focus of reimb from drug sales to cognitive services is possible and can be created by a collaborative effort between payers and providers with minimal impact to overall phys revenue. Despite the parity that can be achieved, phys continue to prefer the “buy and bill” model. Evaluation of changes in phys patterns of care due to this reimb methodology is ongoing.