>> GOOD AFTERNOON. AND WELCOME TO THIS PUBLIC MEETING OF THEPHYSICIAN FOCUSED PAYMENT MODEL TECHNICAL ADVISORY COMMITTEE KNOWN AS PTAC. WELCOME TO THE MEMBERS OF THE PUBLIC WHO AREABLE TO ATTEND IN PERSON. AND ALSO WELCOME TO THOSE ON THE PHONE. OR OVER THE LIVE STREAM. AGAIN, THANK YOU ALL FOR YOUR INTEREST INTHIS MEETING. THIS IS PTAC’S SIXTH PUBLIC MEETING THAT INCLUDESDELIBERATIONS AND VOTING ON PROPOSED MEDICARE PHYSICIAN-FOCUSED PAYMENT MODEL SUBMITTEDBY MEMBERS OF THE PUBLIC.THIS MEETING MARKS TWO YEARS OF THE PTAC BEINGOPEN FOR BUSINESS AND AVAILABLE TO RECEIVE MODELS FROM THE PUBLIC. OVER THE LAST TWO YEARS, INCLUDING THE PROPOSALWE WILL DELIBERATE ON TODAY, WE’VE RECEIVED 28 FULL PROPOSALS. WE THANK THE COMMUNITY OF STAKEHOLDERS WHOHAVE PUT IN THE TIME AND ENERGY TO SUBMIT THESE PROPOSALS. YOUR HARD WORK AND DEDICATION TO IMPROVINGOUR HEALTH CARE SYSTEM IS GREATLY APPRECIATED. I HAVE SOME UPDATES I WOULD LIKE TO SHAREBEFORE OUR DELIBERATIONS GET UNDERWAY. FIRST, YOU MAY NOTICE NEW FACES AROUND THETABLE. WE HAVE ONE NEW FACE, DR. JENNIFER WILER, WHO COMES FROM THE UNIVERSITYOF COLORADO SCHOOL OF MEDICINE, SHE’S AN EMERGENCY MEDICINE PHYSICIAN.SO WELCOME, JENNIFER. WE Also HAVE ON THE PHONE OUR SECOND NEW MEMBEROF THE PTAC COMMITTEE, ANGELO SINOPOLI, INTERNIST BY TRAINING, IF PRISMA HEALTH, FROM SOUTHCAROLINA, HIS NIGHT WAS SNOWED IN BUT HE’S ACTIVE ON TODAY’S MEETING. THESE Kinfolks ARE ACTIVE LOOKING AT NEW MODELSTHAT WE RECENTLY HAD SUBMITTED TO THE COMMITTEE. IN ADDITION, I’D LIKE TO ACKNOWLEDGE DR. GRACE TERRELL, WHO HAS RECENTLY AGREED TOSERVE AS PTAC VICE CHAIR. HAVING WORKED WITH GRACE ON THE COMMITTEEFOR THE PAST THREE YEARS, I KNOW THE COMMITTEE WILL GREATLY BENEFIT FROM HER LEADERSHIP, EXPERTISE, AND ALSO HER CREATIVITY IN HER NEW ROLE. EMPHASIZE CREATIVITY. SO, THE MEMBERS OF PTAC HAVE BEEN HARD ATWORK SINCE OUR LAST PUBLIC MEETING IN SEPTEMBER. IN ADDITION, Of recommendations, WE’LL BE REVIEWINGTODAY OUR PRELIMINARY REVIEW TEAMS ARE ACTIVELY REVIEWING FOUR PROPOSALS. YOU Too MAY REMEMBER THAT EARLIER THIS YEARWE ISSUED A REQUEST FOR PUBLIC COMMENTS ON PROCESSES, SUMMARY OF PUBLIC COMMENTS ANDACTION, THE COMMITTEE IS ASKING TO TAKE AS A RESULT CAN BE FOUND ON THE WEBSITE.TODAY WE WILL ALSO BE DEBUTING NEW VOTINGCATEGORIES FOR RECOMMENDATION TO THE SECRETARY. WE Speculate THAT THESE VOTING CATEGORIES WHICHARE MORE DESCRIPTIVE WILL BE ABLE TO BETTER REFLECT OUR DELIBERATIONS AND RECOMMENDATIONSTO THE SECRETARY. AFTER WE VOTE ON WHETHER THE PROPOSAL MEETSEACH CRITERION WE’LL VOTE ON OVERALL RECOMMENDATION TO THE SECRETARY. FIRST, WE WILL VOTE USING THE FOLLOWING THREECATEGORIES, NOT RECOMMENDED FOR IMPLEMENTATION AS A PHYSICIAN FOCUSED PAYMENT MODEL, SECONDCATEGORY IS RECOMMEND, THE THIRD IS REFERRED FOR OTHER ATTENTION BY HHS. WE NEED TO ACHIEVE A 2/3 MAJORITY OF VOTESFOR ONE OF THE THREE Lists, IF 2/3 MAJORITY VOTES TO RECOMMEND PROPOSAL WE VOTE ON A SUBSETOF CATEGORIES TO DETERMINE THE FINAL OVERALL RECOMMENDATION TO THE SECRETARY, THE SECONDVOTE USES THE FOLLOWING FOUR SUBCATEGORIES. FIRST, PROPOSAL SUBSTANTIALLY MEETS THE SECRETARY’SCRITERIA FOR PFPMs, PTAC RECOMMENDS PROPOSAL AS PAYMENT MODEL. SECOND, PTAC RECOMMENDING FURTHER DEVELOPINGAND IMPLEMENTING PROPOSAL AS PAYMENT MODEL, AS SPECIFIED BY THE PTAC COMMENTS.THIRD, PTAC RECOMMENDS TESTING PROPOSAL ASSPECIFIED IN PTAC COMMENTS TO INFORM PAYMENT MODEL DEVELOPMENT. FOURTH, PTAC RECOMMENDS IMPLEMENTING THE PROPOSALAS PART OF AN EXISTING OR PLANNED CMMI MODEL. WE NEED A 2/3 Majority FOR ONE OF THESE FOURCATEGORIES. TODAY WE WILL DELIBERATE ON ONE PROPOSAL BEFOREWE HOST A GENERAL PUBLIC COMMENT PERIOD. TO REMIND THE AUDIENCE, THE ORDER OF ACTIVITIESFOR THE PROPOSAL IS AS FOLLOWS. FIRST PTAC MEMBERS WILL MAKE DISCLOSURES OFPOTENTIAL CONFLICTS OF INTEREST AND ANNOUNCE WHETHER THEY WILL NOT DELIBERATE AND VOTE. SECOND, DISCUSSION OF THE PROPOSAL WILL BEGINWITH THE PRESENTATION BY THE PRELIMINARY REVIEW TEAM. FOLLOWING THE PRT PRESENTATION AND INITIALQUESTIONS FROM PTAC MEMBERS, THE COMMITTEE LOOKS FORWARD TO HEARING COMMENTS FROM THEPROPOSAL SUBMITTER AND THE PUBLIC. THE COMMITTEE WILL DELIBERATE ON THE PROPOSAL, AS A DELIBERATION CONCLUDES I’LL ASK THE COMMITTEE WHETHER THEY ARE READY TO VOTE ON THE PROPOSAL, IF THE COMMITTEE IS READY EACH COMMITTEE MEMBER WILL VOTE ELECTRONICALLY ON WHETHER THE PROPOSALMEETS EACH OF THE SECRETARY’S TEN CRITERIA, NOT CHANGED FROM PUBLIC MEETINGS.THE LAST VOTE ON AN OVERALL RECOMMENDATIONTO SECRETARY OF HEALTH AND HUMAN SERVICES Exploiting THE TWO-PART VOTING SYSTEM I DESCRIBED. FINALLY I’LL ASK EACH PTAC MEMBER TO PROVIDEGUIDANCE AS ASPE STAFF TO ASPE STAFF ON KEY COMMENTS TO INCLUDE IN THE REPORT TO THE SECRETARY. A FEW REMINDERS, AS WE BEGIN DISCUSSIONS TODAY, ONE, PRT REPORTS ARE REPORTS FROM THREE PTAC MEMBERS TO THE FULL PTAC AND DO NOT REPRESENTA CONSENSUS OR POSITION OF THE PTAC. THESE PRT REPORTS ARE NOT BINDING. THE FULL PTAC MAY REACH A DIFFERENT CONCLUSIONFROM THOSE CONTAINED IN THE PRT REPORT. AND FINALLY, THE PRT REPORT IS NOT A FINALREPORT TO THE SECRETARY OF HEALTH AND HUMAN SERVICES, AFTER THIS MEETING PTAC WILL WRITEA NEW REPORT THAT Manifests DELIBERATIONS AND DECISIONS OF THE PULL PTAC, THEN WILL BE SENTTO THE SECRETARY. OUR JOB IS TO PROVIDE THE BEST POSSIBLE RECOMMENDATIONSFOR THE SECRETARY, AND I EXPECT THAT OUR DISCUSSIONS THIS AFTERNOON WILL ACCOMPLISH THIS GOAL. I WOULD LIKE TO Make THIS OPPORTUNITY TO THANKMY PTAC COLLEAGUES, ALL OF WHOM HAVE GIVEN COUNTLESS HOURS TO THE CAREFUL AND EXPERTREVIEW OF THE PROPOSALS WE RECEIVE. THANK YOU AGAIN FOR YOUR WORK.AND THANK YOU TO THE PUBLIC FOR PARTICIPATINGIN TODAY’S MEETING IN PERSON VIA LIVE STREAM OR ON THE PHONE. SO BEFORE WE GET STARTED, I WOULD LIKE TOFOLLOW UP TO A DISCUSSION THAT WE HAD AT THE LAST PUBLIC MEETING WHICH WAS PROVIDING ANUPDATE ON THE STATUS OF THE SECRETARY’S RESPONSE TO OUR DISCUSSION AROUND THE MODELS THAT WE’VEALREADY APPROVED, AND WHAT CMMI, WHAT ACTIVITIES CMMI HAS BEEN DOING TO DATE. WE CONCLUDED A CALL WITH DIRECTOR OF CMMIADAM BOEHLER, WE’VE BEEN SPEAKING BETWEEN THE LAST MODEL AND TODAY. THERE ARE MODELS IN FLIGHT THAT ARE BASEDON THE SUBMISSIONS FROM THE PROPOSERS THAT ARE GOING THROUGH THE APPROVAL PROCESS NOW. WE’RE NOT CERTAIN OF THE EXACT TIMING WHENTHE MODELS WILL BE ANNOUNCED. BUT WE Anticipate THAT IT WILL BE SOMETIMEIN THE FIRST QUARTER OF 2019, OF NEXT YEAR. SOME OF THE CATEGORIES THAT ARE UNDER CONSIDERATIONINCLUDE PRIMARY CARE MODEL, KIDNEY CARE MODEL, END OF LIFE MODEL, AND THERE ARE OTHERS UNDERCONSIDERATION THAT WE’LL HEAR MORE ABOUT HOPEFULLY BY THE NEXT MEETING.ADAM PLANS TO ADAM BOEHLER PLANS TO COME ANDADDRESS THE PUBLIC AT THE NEXT MEETING. THERE ARE ALSO OTHER THERE’S A LETTER THATIS UNDER CONSTRUCTION THAT WILL BE RELEASED SOON THAT WILL INCLUDE GUIDANCE ON THE AREASOF FOCUS THAT CMMI IS INTERESTED IN DRIVING FORWARD RELATIVE TO ALTERNATIVE PAYMENT MODELS. AND THAT CRITERIA WILL INCLUDE THE KINDS OFMODELS THAT THEY ARE Looking forward to, THE KINDS OF ELEMENTS THAT WILL BE IN THOSE MODELS THATWILL TAKE PARTICULAR INTEREST FROM CMMI. AND I WELCOME MY PTAC COLLEAGUES WHO HAVEBEEN IN THOSE DISCUSSIONS WITH ADAM, BUT WE Mull THAT THIS EXTRA GUIDANCE WILL BE HELPFULAS STAKEHOLDERS FIGURE OUT WHETHER TO COME TO PTAC TO WORK DIRECTLY WITH CMMI, WE THINKTHIS LETTER WILL INCLUDE GUIDANCE HOW TO NAVIGATE THAT DECISION MAKING BASED ON THE PROPOSALELEMENTS THAT ARE UNDER CONSIDERATION.WHICH WILL HELP THE SUBMITTERS PRIOR TO ACTUALLYCREATING AND GOING INTO DEPTH AND BUILDING A PROPOSAL WITH THIS GUIDANCE THEY WILL BEABLE TO INCORPORATE SOME OF THE ANTICIPATED ATTENTION THAT CMMI WILL BE TAKING FUTURISTICALLYWHICH WILL HELP US A AS COMMITTEE AND THE STAKEHOLDERS COMMITTEE ON WHAT MAKES SENSEGOING FORWARD. BEFORE I Propel INTO THE REVIEW OF THE MODELTODAY, DO ANY OF MY COLLEAGUES WANT TO ADD TO MY COMMENTS SUMMARIZING THE UPDATE? SANDY MARKS FROM AMA WILL MAKE ADDITIONALCOMMENTS, WHO HAS BEEN SPEAKING WITH STAKEHOLDERS TO GET THEIR INPUTS, PROPOSALS WORKING WITHCMMI, WE’LL HEAR MORE ABOUT THAT. DID I MISS ANYTHING RELATIVE TO THE UPDATEWE WANTED TO PROVIDE AS A COMMITTEE TODAY? ALL RIGHT. HEARING NONE, LET’S GET STARTED. THE PROPOSAL WE WILL DISCUSS TODAY IS CALLEDMAKING ACCOUNTABLE CARE SUSTAINABLE ONCOLOGY NETWORKS, OR MASON, SUBMITTED BY INNOVATIVEBUSINESS SOLUTIONS INCORPORATED. WE’LL HEAR FROM THE PRT. OH, BEFORE WE DO THAT WE HAVE TO HAVE OURDISCLOSURES, OUR CONFLICT OF INTEREST DISCLOSURES. AND I’LL START WITH MYSELF AND INTRODUCE EACHOTHER AS WELL. JEFF BAILET, EXECUTIVE VICE PRESIDENT FORHEALTH CARE QUALITY AND AFFORDABILITY WITH BLUE SHIELD OF CALIFORNIA.ON THIS PARTICULAR PROPOSAL I HAVE ONE DISCLOSURETO SHARE. I Performed ON THE AMERICAN MEDICAL ASSOCIATIONLARGE GROUP ADVISORY BOARD ADVISING AMA BOARD OF DIRECTORS FOR FOUR YEARS ENDING IN 2012. DR. MCANENY WAS ON THE BOARD AT THE TIME AND ATTENDEDOUR QUARTERLY MEETINGS FOR THE LAST YEAR OR SO. I Vouched BEFORE CONGRESS AS ONE OF FOURPHYSICIANS INCLUDING BARBARA IN APRIL OF 2016, I’VE INDICATED THESE ITEMS ON THE FORM BUTI DON’T FEEL THAT THEY REPRESENT A SIGNIFICANT CONFLICT BUT WANT THE COMMITTEE AND FOLKSAT ASPE TO BE AWARE. >> BRUCE STEINWALD, HEALTH COMMISSION. >> PAUL CASALE, NO DISCLOSURES. >> HAROLD MILLER. I WAS NOT INVOLVED IN THIS PROPOSAL, I WOULDNOT HAVE EFFECT ON ME BUT I HAVE WORKED WITH DR. MCANENY ON ONCOLOGY PAYMENT ISSUES, WHEN IREAD THROUGH, I Realise PART OF THE MODEL IS BASED ON THE PATIENT CENTERED ONCOLOGYPAYMENT MODEL THAT I WORKED WITH THE AMERICAN SOCIETY OF CLINICAL ONCOLOGY ON SEVERAL YEARSAGO AND VISITED DR.MCANENY’S PRACTICE IN NEW MEXICO, THE ALBUQUERQUEVERSION OF THE PRACTICE, AND HAVE PROVIDED INFORMATION TO HER AND TO LAURA STEVENS, THECOO OF IOBS, ON SEVERAL OCCASIONS. I ALSO DO CONSULTING WORK FOR THE AMERICANMEDICAL ASSOCIATION AND DR. MCANENY IS THE CURRENT PRESIDENT OF AMA. I DON’T HAVE ANY FINANCIAL CONFLICTS, JUSTTO AVOID ANY APPEARANCE OF BIAS OR FAVORITISM I’M GOING TO RECUSE MYSELF FROM VOTING ANDFROM PARTICIPATING IN THE DELIBERATION ON THE PROPOSAL. I DO KNOW A LOT ABOUT ONCOLOGY PAYMENT INGENERAL, IF THERE ARE FACTUAL QUESTIONS ABOUT THE CURRENT PAYMENT SYSTEM I WOULD BE HAPPYTO ANSWER FOR MY COLLEAGUES IF HELPFUL BUT I’M NOT GOING TO ENGAGE IN DELIBERATION ONTHE PROPOSAL ITSELF .>> JENNIFER WILER, PROFESSOR OF EMERGENCYMEDICINE AT UNIVERSITY OF COLORADO, ALSO EXECUTIVE MEDICAL DIRECTOR UC HEALTH CARE INNOVATIONCENTER, NOTHING TO DISCLOSE. >> LEN NICHOLS, CENTER FOR HEALTH RESEARCHAND ETHICS GEORGE MASON UNIVERSITY, HEALTH ECONOMIST, I DON’T HAVE ANYTHING THAT RISESTO LEVEL OF RECONFLICT BUT SINCE WE’RE BEING SO OPEN AND HONEST I ONCE HAD A DRINK WITHBARBARA IN A BAR, IT WAS WITH IAN MORRISON FROM CANADA, AND HE PAID FOR THE DRINK BECAUSEHE MAKES MORE MONEY THAN WE DO. >> GRACE TERRELL, CEO OF ENVISION GENOMICS, PRACTICING GENERAL INTERNIST AT WAKE FOREST BAPTIST HILL SYSTEM, ON THE BOARD OF CHESS, A POPULATION HEALTH MANAGEMENT COMPANY, AND I HAVE NO CONFLICTS TO DISCLOSE .>> DR. SINOPOLI? >> YES, THIS IS DR. SINOPOLI, A PULMONARY CRITICAL CARE PHYSICIAN, CHIEF CLINICAL OFFICER FOR PRISMA HEALTH IN SOUTH CAROLINA, ALSO CEO OF CARE COORDINATIONINSTITUTE ENABLEMENT Work COMPANY, NO CONFLICTS, NOTHING TO DISCLOSE. >> THANK YOU. SO WE’RE GOING TO TURN IT OVER TO THE PHYSICIANTHE PROPOSAL REVIEW TEAM AND THAT’S LED BY DR. GRACE TERRELL. GRACE? >> Expressed appreciation for, JEFF. THANKS, EVERYBODY. ONE OF THE COOLEST THINGS I THINK ABOUT PTACAND MACRA LEGISLATION, IF WE TAKE ADVANTAGE OF IT, IS AT LEAST THE ONLY EXAMPLE I KNOWOF WHERE THE FEDERAL GOVERNMENT ASKS THE STAKE HOLDERS WHO ACTUALLY PRACTICE MEDICINE ANDRUN MEDICAL BUSINESSES TO CONTRIBUTE TO THE ABILITY TO THINK ABOUT HEALTH CARE POLICYIN WAYS THAT CAN MAKE A DIFFERENCE FOR ALL OF US. AND SO WITHIN THAT CONTEXT, I VERY MUCH ANDMY COLLEAGUES APPRECIATE THE MASON PROPOSAL. IT COMES FROM THE CONTEXT OF AN ORGANIZATIONTHAT HAS PARTICIPATED IN THE ONCOLOGY CARE MODEL THAT’S NOW ONE OF THE STANDARD MODELSTHAT’S BEEN ONE OF THROUGH COME HOME, ONE OF THE HCIA AWARDS THAT LOOKED AT HOW TO THINKABOUT MODELS OF CARE THAT WOULD MAKE A DIFFERENCE WITH RESPECT TO Riches AND HOW THEY MIGHTBE BETTER USED TO PROVIDE CARE FOR PATIENTS WHO HAVE CANCER.AND WHO FROM THAT EXPERIENCE HAD THE ABILITYAS WELLS RUNNING A PRIVATE BUSINESS IN A NONHOSPITAL BASED ONCOLOGY PRACTICE UNDERSTANDING WHATSOME LIMITATIONS WHETHER AS WELL AS LEARNINGS FROM THE TYPES OF THINGS THEY THOUGHT MIGHTMAKE IT BETTER. AND SO OUT OF THAT COMES THE MASON PROPOSAL, AND WITHIN THAT CONTEXT I THINK THE PROPOSALS OF IT AND GRATEFUL THAT WE HAVE THE OPPORTUNITYTO BE THINKING ABOUT THINGS FROM THE FIELD THAT STAKEHOLDERS ARE BRINGING.THIS IS A PERFECT EXAMPLE OF ONE THAT COMESFROM THAT CONTEXT. THE PRT REVIEW COMMITTEE CONSISTED OF MYSELFAS LEAD, BRUCE STEINWALD, AS WELL AS BOB BERENSON BOB IS NOT WITH US, UNLESS HE’S ON THE PHONELISTENING, BECAUSE HE’S ROTATED OFF THE COMMITTEE BUT CERTAINLY HAS BEEN VERY MUCH INVOLVEDIN THE ANALYSIS AND MOST ACTUALLY ALL THE WORK WITH RESPECT TO THIS WAS DONE PRIOR TOHIS ROTATION OFF. I Meditate MAYBE THE HOUR BEFORE OR SOMETHINGLIKE THAT, WE WERE STILL WORKING ON IT BUT GOT IT DONE.SO, MAKING ACCOUNTABLE SUSTAINABLE ONOLOGYNETWORKS IS THE PROPOSAL, WE HEARD ABOUT THE PRT AND WHO WE ARE. THE PROPOSAL OVERVIEW FOR THOSE WHO ARE FAMILIARWITH OUR PROCESS, I WON’T GO THROUGH IT IN GREAT DETAIL BECAUSE IT’S BECOME A REAL STANDARD, THIS Were the same. AT LEAST FROM MY POINT OF VIEW WAS THE FIRSTI WAS INVOLVED IN, SINCE THE CHANGE IN LEGISLATION, THAT ALLOWED US TO GIVE PRELIMINARY FEEDBACK. SO IN MANY WAYS IT MAY HAVE PROLONGED THEREVIEW PROCESS, WHICH IS WHY IT WAS NOT DONE IN SEPTEMBER LIKE WE ORIGINALLY THOUGHT ITWAS, BUT IS HERE IN DECEMBER. BOB HAD ACTUALLY ALREADY ROTATED OFF AT THATPOINT.ON THE OTHER HAND, WE’VE LEARNED FROM THATPROCESS AND I BELIEVE THAT AS A RESULT OF THAT SEVERAL CHANGES THAT OCCURRED MADE THISAT LEAST FROM THE PRT’S PERSPECTIVE A STRONGER PROPOSAL. SO TYPICALLY WHAT HAPPENS IS THAT THE PTACCHAIR VICE CHAIR ASSIGNED TWO TO THREE PTAC MEMBERS TO REVIEW. THEN ADDITIONAL INFORMATION IS REQUESTED. IN THIS CASE WE SPOKE TO OAC, TO CMMI, BOTHCASES ABOUT THE ONCOLOGY CARE MODEL THAT WAS OUT THERE AS WELL AS THE COME-HOME AWARD THATTHIS SAME GROUP HAD BEEN INVOLVED WITH. WE Asked IN WRITTEN QUESTIONS OF THE PROPOSER, GOT THOSE BACK, HAD AN INTERVIEW WITH THEM, AND THEN SUBSEQUENT TO THAT CREATED A SORTOF EARLY PRT TYPE REPORT THAT WAS ALLOWED TO BE THE INITIAL FEEDBACK. THAT’S THE NEW COMPONENT OF THAT. FROM THAT WE GOT MORE ITERATIONS, MORE INTERVIEWS, MORE DISCUSSIONS, MORE ANSWERS, AND ULTIMATELY SOME CHANGES FROM THEIR ORIGINAL PROPOSAL. AND SUBSEQUENT TO THAT, WE WROTE UP OUR RECOMMENDATIONSWHICH YOU ALL HAVE SEEN AND WHICH I’LL GO OVER AS WE GO FORWARD WITH IT.BUT THAT WAS THE PROCESS THAT WE WENT THROUGH. IT WAS QUITE THOROUGH AND WE HAD A SIGNIFICANTAMOUNT OF INFORMATION THAT WE EVALUATED, BOTH FROM THE PROPOSER THEMSELVES WRITTEN AND ORALLYBUT ALSO FROM OTHER SOURCES. SO THIS PARTICULAR MODEL AND PROPOSAL IS BASEDUPON COME HOME. SO COME HOME WAS PART OF A CMMI GRANT THATWAS DONE FROM A GROUP OF ONCOLOGISTS, THAT WERE PART OF A CONSORTIUM. AND WITH THAT, THEY CREATED OUT OF THAT GRANTSOME PROCESSES IN PLACE FOR WHICH THEY WERE ABLE TO SHOW THAT CARE COORDINATION AND OTHERTYPES OF PROCESSES THAT THEY DEVELOPED SAVED SUBSTANTIAL MONEY OFF THE AWARDS ONCE THEYWERE EVALUATED. I Repute IT WAS SOMETHING LIKE 6.3% OVERALL, SOME OF THAT WAS REDUCTION IN HIGH COST SERVICES LIKE EMERGENCY DEPARTMENTS. AND Located UPON THAT, WHICH WAS NOT SUSTAINABLE, SINCE IT WAS PART OF JUST A GRANT AND THE AWARD, THEY THEN DID A LOT OF SUBSTANTIALTHINKING ALSO BY PARTICIPATING IN THE ONCOLOGY CARE MODEL ON A PAYMENT MODEL THAT MIGHT OCCURTHAT COULD IMPROVE ON THAT WORK AS WELL AS CREATE THE OPPORTUNITY FOR SOMETHING THATCOULD BE SUSTAINABLE AS PART OF THE PTAC PROPOSAL THAT WENT TO CMMI.SO THAT’S WHAT THIS IS. THE CORE ELEMENTS ARE THAT IT STARTS WITHTHE FIRST CONSULTATION WITH AN ONCOLOGIST, IT’S Located ON THE RELEVANT CLINICAL FACTORSAND PATIENT PREFERENCES. MANY OF THIS IS WORK DONE RELATED TO THINKABOUT THE COME HOME CARE MODEL. THEY WERE Designated TO A TREATMENT PLAN ATTHAT POINT. THAT HAS A TARGET PRICE THAT IS ESSENTIALLYREFLECTS ALL CANCER CARE RELATED EXPENSES BUT EXCLUDES DRUGS FROM THE OVERALL OPC, WHICHIS A TARGET AMOUNT THAT IS ESTABLISHED, BASED UPON PRACTICE PATHWAYS, AS WELL AS SOME ARTIFICIALINTELLIGENCERELATED WAYS OF THINKING THROUGH IN GREAT DETAIL THE PRICING THAT MIGHT BEAPPROPRIATE FOR THAT LEVEL OF CARE. THE OPC ASSIGNMENT PROMPTS CREATION OF A VIRTUALCOUNT. THE USUAL TYPES OF FEES ARE CHARGED IN THEUSUAL TYPES OF WAY, WHETHER DRG OR WHETHER IT’S FEE FOR SERVICE PHYSICIAN PAYMENTS. AND ALL THAT IS KEPT IN A VIRTUAL ACCOUNTAND RETROSPECTIVELY BASED ON WHAT COSTS WOULD BE THERE’S A TRUE-UP AT THE END. IF PATIENTS WERE MANAGED TO REDUCE EXPENDITURESBELOW TARGET AMOUNT PRACTICE SHARES IN THE SAVINGS, PROVIDES THE BENCHMARKS ARE SUFFICIENTLYMET.AND QUALITY IS MEASURED BY PATHWAY COMPLIANCEPATIENTS FAMILY SURVEYS, PATHWAYS ARE ESTABLISHED AND DEVELOPED BY THIS NATIONAL CONSORTIUMBASED ON EVIDENCEBASED GUIDELINES THAT IS ALSO WITH CONTRIBUTION FROM THE ACADEMIC CENTERSAS IT RELATES TO THESE GUIDELINES. BECAUSE OF THE NATURE OF ONCOLOGY PRACTICE, WHICH IS CHANGING FASTER THAN EVERYTHING ELSE, NOT ONLY AS IT RELATES TO DRUGS BUT AS WELLAS GENOMICS, MANY OF THE OTHER ASPECTS OF CARE CHANGING IN REAL TIME, THE OPCs ARE AWORK THAT CHANGES OVER TIME.THAT’S ONE OF THE REAL ISSUES IN THIS MODELTHAT WE NEED TO THINK ABOUT BECAUSE IT’S SOMETHING THAT HAS TO BASICALLY SET ESTABLISHED PRICINGBUT AT THE SAME TIME HAS TO GO FOR BEST EVIDENCE IN REAL TIME, IN SOMETHING THAT’S CHANGINGVERY, VERY RAPIDLY. SO THOSE ARE THE ISSUES THAT THIS MODEL TRIEDTO RESOLVE AND SOLVE AND COME UP WITH A SOLUTION WITH THAT IN ONE OF THE MOST COMPLEX AREASTHERE IS IN HEALTH CARE TODAY. SO, TO BASICALLY THINK ABOUT THIS, THERE’SA TARGET PRICE CALLED AN OPC. AND THESE ARE BASICALLY ESTABLISHED BASEDON DISEASE STATE, COMORBIDITIES, TREATMENT PLAN THAT’S THE EXPECTED COST OF CARE FORPATIENTS IN A GIVEN OPC.IT’S REALLY IMPORTANT WHEN YOU SEE THE PRT’SEVALUATIONS TO UNDERSTAND THESE HAVE NOT BEEN DEVELOPED YET.AND THAT’S REALLY ONE OF THE KEYS TO SOME OF THE ANALYSIS THAT WE HAD. I DON’T Undoubtedly PERSONALLY THINK THATMEANS THAT IT’S A NEGATIVE OR ADVERSE RECOMMENDATION THAT WE GIVE. IT Precisely MEANS THEY ARE NOT DEVELOPED More. THIS IS AN ONGOING Arena, A Mas HAS TO BETHOUGHT THROUGH WITH RESPECT TO HOW YOU GET FROM POINT A TO POINT B IN A SYSTEM THAT’SEVOLVING IN REAL TIME. THERE’S A ONE Occasion $750 PAYMENT FOR NEW PATIENTCONSULTATION. E& M VISITS ARE PARTS OF THAT. INFUSE CENTER FEES ARE PART OF THAT AS WELLAS RADIATION INPUT, HOSPITAL CHARGES, FACILITY FEES, ANY PHYSICIAN CARE THAT’S RELATED TOCANCER TREATMENT.IMAGING AND LABORATORY Services, BUT EXCLUDESNON-ONCOLOGY Service. SO PART OF THE REAL ASPECT OF THIS MODEL, IT’S RELATED TO CANCER CARE. AND THOSE THINGS THAT THE ONCOLOGISTS CANCONTROL. QUALITY IS BASED UPON 4% WITHHOLD FROM E& MPAYMENTS, USED TO FORM A QUALITY POOL. QUALITY IS MEASURED BY TECHNICAL QUALITY INTERMS OF LOOKING AT ITS VARIATION FROM TREATMENT PATHWAYS THAT HAVE BEEN ESTABLISHED. AND CUSTOMER SERVICE QUALITY IN TERMS OF PATIENTFAMILY SURVEYS. AND FOR BOTH CRITERIA THERE’S AN 80% THRESHOLDESTABLISHED AS DEFINING SATISFY PERFORMANCE. SO, TO SUMMARIZE THE PRT REVIEW, WE FELT THATTHE SCOPE WHICH IS ONE OF OUR HIGH PRIORITY DESIGNATIONS THAT THIS ABSOLUTELY MEETS CRITERIAAND DESERVED CONSIDERATION, CANCER CARE IS HIGHLY COMPLEX, THE ENTIRE BUSINESS IS CHANGING. THIS PARTICULAR MODEL IS BASED ON SOME VERYDEEP THINKING FROM PEOPLE IN THE FIELD RUNNING A BUSINESS, TRYING TO UNDERSTAND HOW IT MIGHTBEST BE MODELED IN WAYS FROM A PAYMENT AND DELIVERY STANDPOINT THAT COULD BE SUSTAINABLEGIVEN THE CHANGES THAT ARE GOING ON.FROM A QUALITY AND COST PERSPECTIVE IT WASUNANIMOUS IT DID NOT MEET, MOSTLY RELATED TO THE FACT OPCs HAVE NOT BEEN FULLY DEVELOPEDAND ESTABLISHED, AND OPERATIONAL YET. LIKEWISE FOR THE PAYMENT METHODOLOGY, DOESNOT MEET BASED UPON THE SAME ETIOLOGY OF RATIONALE AND REASONING BASED ON OUR PART. VALUE OVER VOLUME, THIS IS FLEXIBLE RELATIVETO OTHER Alternative. ABILITY TO BE EVALUATED WE BELIEVE IT MEETSTHE INTEGRATION CARE COORDINATION, WE BELIEVE IT MEETS PARTICULARLY AS RELATES TO THE COMEHOME THINGS THAT HAVE BEEN DEVELOPED AND ESTABLISHED, PATIENT CHOICE, PATIENT SAFETY AND HEALTHINFORMATION TECHNOLOGY WE ALL BELIEVE IT Fulfils. SO WE IDENTIFY SOME KEY ISSUES. FIRST ONE I’VE ALREADY MENTIONED, WHICH ISOPCs ARE NOT Currently OPERATIONAL. AND DEVELOPING THEM IS GOING TO BE A TIMEINTENSE PROCESS THAT WILL REQUIRE FREQUENT AND SIMILARLY TIME INTENSIVE UPDATES, TO REFLECTEVER EVOLVING DEVELOPMENTS TO PHARMACOLOGIST, THERAPEUTICS AND DIAGNOSTIC TESTING ACTUALLYWITH RESPECT TO GENETICS, THE ONGOING REALITY OF THE CURRENT SITUATION ONCOLOGY.THERE IS A GRANULARITY OF CARE THAT THE OPCsARE EVALUATING THAT IS MUCH MORE GRANULAR THAN WHAT WE CURRENTLY SEE IN THE ONCOLOGYCARE MODEL THAT’S ONE OF THE CMMI MODELS OR OTHER THINGS OUT THERE RIGHT NOW. BUT THEY ARE Located ON UTILIZATION PATTERNSTHAT WOULD BE FROM A SELECT GROUP OF PRACTICES THAT MAKE UP THIS CONSORTIUM. AND SO ONE OF THE Edition OUT THERE WAS CANTHIS BE GENERALIZED FOR THE ENTIRE POPULATION THAT DOES ONCOLOGY IN THE U.S. OR NOT. SO THIS ISN’T ANYTHING WE NECESSARILY THINKCAN’T OR WON’T BE DONE BUT HAS TO BE EVALUATED FURTHER SINCE THIS IS JUST A SMALL GROUP OFONCOLOGISTS, THERE ARE A GROUP OF ONCOLOGISTS THAT ARE ALREADY PRETTY EVOLVED, IF YOU WILL, WITH RESPECT TO LOOKING AT ALTERNATIVE PAYMENT MODELS AND WORKING WITH SOME OF THE CHANGESTHAT ARE GOING ON OUT THERE. WE WERE Too CONCERNED ABOUT COMPLIANCE WITHINTHE PATHWAYS AND HOW THEY WERE ASSIGNED, WHETHER DEVIATIONS THAT ARE VOLUNTARY CAN BE DISTINGUISHEDFROM UNEXPECTED EVENTS THAT TRIGGER CLINICALLY NECESSARY PROTOCOL CHANGES. SO THIS, AGAIN, IS PART OF THE ISSUE OF IFYOU DON’T HAVE THIS THING ENTIRELY BAKED YET BECAUSE YOU HAVE TO BAKE IT, WE Merely DON’TKNOW THAT WE’VE GOT THAT LEVEL OF DETAIL FIXED YET.WE HAD SOME OPERATIONAL CONCERNS ABOUT THEADJUDICATION OF CLAIMS AND SERVICES BASED UPON SOME OF THE DESCRIPTION OF IT IN THEREPORT, IN THE PROPOSAL THAT WE GOT. WHEN WE WENT BACK AND ASKED IN MORE DETAIL, THERE WAS SOME MORE INFORMATION THAT WAS PROVIDED TO US ABOUT LOOKING AT CLUSTER CODES TO HELPUS MAKE THOSE DETERMINATIONS. AGAIN, THE ISSUE WAS THAT AS OPPOSED TO APPEALSPROCESS, THE ISSUE WAS THIS IS NEW MACHINE LEARNING TYPES OF APPROACHES, AND HAS NOTAS OF YET IT’S BEEN UNTESTED. WE BELIEVE THE CLINICIANS HAVE THE OPPORTUNITYTO GO AND JUSTIFY BEING OFF PATHWAY BUT WE DON’T KNOW HOW THEY WILL BE REALLY FACTOREDINTO THE QUALITY SCORING. SO YOU GET THE SENSE WE FOUND CONCERNS, THEDETAILS IN MANY RESPECTS THAT HAVE NOT YET BEEN DEVELOPED.MODELS EFFORT TO DELINEATE CANCER AND NONCANCERCARE MAY DISINCENTIVIZE CARE BETWEEN CORE TEAM MEMBERS OF CANCER CARE PROVIDERS. THE PRT WOULD LIKE TO SO A ROBUST AND DETAILEDPLAN FOR SHARED DECISION MAKING. A Lot OF THE THIS STARTS AT TREATMENT PLANWHEN THE PAYMENT STARTS FOR INITIAL CONSULTATION WE BELIEVE ALL THE WAY THROUGH MORE DEVELOPMENTOF LANGUAGE AROUND SHARED DECISION MAKING COULD MAKE THIS A STRONGER PROCESS. AND THE PROCESS FOR IMPLICATIONS OF PATIENTSEXITING THE MODEL PROBABLY NEED TO BE MORE FULLY DESCRIBED AND UNDERSTOOD. SO, I’M GOING TO GO QUICKLY THROUGH THE CRITERIATO HAVE ADEQUATE TIME TO GO IN GREATER DETAIL WITH THE PROPOSERS THEMSELVES AND SO THE COMMITTEEMEMBERS CAN ASK MORE DETAILED QUESTIONS. AGAIN, WE THOUGHT THAT THE IT MET THE SCOPE. WE Meditate IT’S Actually IMPORTANT FOR THERE TOBE ALTERNATIVE PAYMENT MODELS IN ONCOLOGY ABOVE AND BEYOND WHAT’S CURRENTLY OUT THEREWITH THE CURRENT MODEL. THIS Overture Acknowledges THE GRANULARITYAND IT IS NOT BASED ON PRE DEFINED TIME FRAME WHICH WE LIKE AS OPPOSED TO CURRENT MODELOUT THERE WHICH STARTS SPECIFICALLY WITH THE INITIATION OF CHEMO AND ONLY GOES FOR SIXMONTHS, AND AS THE Proposals MADE PERFECTLY CLEAR TO US THAT’S NOT NECESSARILY THE WAYCANCER WORKS FOR A PATIENT IN THE REAL WORLD.AND THE TYPE OF THOUGHTS ON THIS THEY PUTINTO ALTERNATIVE PAYMENT MODELS AROUND THERE IS REALLY LOOKING AT TIME OF TREATMENT ASNOT TIME BASED WE FELT WAS A REAL POSITIVE. THERE IS DIRECT INCENTIVIZATION FOR CARE COORDINATION, HOLDING ACCOUNTABLE FOR CANCER RELATED EXPENDITURES, WHICH THEY Maintain THEY DO NOT HAVE. CRITERIA AND COST, AS I Mentioned earlier, A Plenty OF THIS HAS NOT BEEN COMPLETELY BAKED OR DEVELOPED YET. NONETHELESS, USING EVIDENCE BASED TREATMENTPATHWAYS AND REWARDING BASED ON CLINICAL QUALITY IS A CLEAR STRENGTH OF THE PROPOSAL CONCEPTUALLYAND ONE THAT WE Accept IF IT Extends FORWARD OUGHT TO BE DEVELOPED AND DEVELOPED IN GREATDETAIL.WE WERE CONCERNED ABOUT HOW THESE THINGS WOULDBE DONE, HOW THE TARGET PRICES WOULD BE ESTABLISHED SINCE IT’S NOT CURRENTLY OPERATIONAL. THEY equipped SOME DETAIL WITH RESPECT TOTHAT BUT THE BIGGEST HANGUP WE HAD IS IT JUST WASN’T OPERATIONAL YET. SO IT WAS A Plenty WAS IN THINKING THROUGH APROCESS THEY WOULD LIKE TO PUT IN PLACE. IT WAS Likewise CONCERN ABOUT THE GENERALIZABILITYOF THIS, Located AGAIN ON THE PATTERNS OF THE CURRENT GROUP. AND THEN THE COMPLIANCE WITH THE PATHWAYS, MAYBE YOU SHOULDN’T BE COMPLIANT. THIS IS IN IN ANYTHING YOU MEASURE THERE’SALWAYS THE POTENTIAL MEASUREMENT CAN LEAD TO ADVERSE OUTCOMES AS PEOPLE’S BEHAVIOR ISCHANGED BY THAT. THIS WILL BE TRUE IN ANYTHING THAT IS ESTABLISHED, SO THE REAL ISSUE IS NOT THAT THIS MEANS IT SHOULDN’T BE DONE BUT NEEDS TO BE ACKNOWLEDGEDAND MANAGED.FROM THE PAYMENT METHODOLOGY AGAIN THE CLEARSTRENGTH OF THE PROPOSAL, ATTENTION TO CARE, COORDINATION, BASED UPON THE COME HOMEWORKTHAT WAS DONE THAT HAD COST OF CARE AND HIGH QUALITY ASSOCIATED WITH IT FROM THE PREVIOUSWORK AT CMMI AND FACT IT WAS BASED ON CANCER RARE RATHER THAN TOTAL COST OF CARE. WE WERE SUPPORTIVE OF INCLUSION OF ADMINISTRATIVEFEES, RELATED TO DRUG PURCHASING AND ADMINISTRATION. OBVIOUSLY THERE’S BEEN SOME STUFF THAT’S COMEOUT FROM CMS SINCE THIS PROPOSAL CAME ON. THAT MAY MAKE THAT LESS OF A FACTOR. INITIALLY THERE WAS 2% PLUS INVOICE PRICING, CRITICISM WITH INITIAL FEEDBACK WHEN THEY CAME BACK WITH PROPOSAL THIS WAS WHAT WASPROPOSED. WE LIKE IT BUT THAT MAY BE MOOT NOW GIVENSOME OTHER THINGS THAT’S HAPPENING AT CMS THINKING ABOUT THE DRUG PRICING.THERE WAS THOUGHT PROCESS CODING TO BE USEDTO THINK ABOUT PREDICTORS OF CANCER RELATED EXPENDITURES THAT HAD NOT BECAUSE THAT’S NOTREALLY BEEN DEVELOPED FOR CANCER AS A WAY OF DETERMINING ALTHOUGH IT MAY IDENTIFY PATIENTSAT HIGHER RISK FOR NOT ONLY CANCER RELATED BUT NON CANCER RELATED SEVERITY INDEX, IT’SNEVER ACTUALLY BEEN USED IN THIS WAY SO IT’S SOMETHING THAT WOULD HAVE TO BE THOUGHT ABOUTDIFFERENTLY. THE PROCESS OF ADJUDICATING RELATED TO CANCERCARE OR NOT COULD BE THE NEW FIGHT BECAUSE IT’S GOING TO BE FOR CANCER ONLY WHAT BECOMESCANCER CARE RELATED RELATED TO EXPENDITURES, THESE ARE THINGS THAT HAVE TO BE THOUGHT THROUGH. WITH RESPECT TO VALUE OVER VOLUME REVIEW OFACCOUNTS AND PROCESS OF IDENTIFYING PROVIDERS DELIVERING LOW VALUE CARE AS RELATED TO PATHWAYIS COMPELLING. AND WOULD LIKELY IMPROVE CANCER CARE. THE PAYMENT MODEL ADDRESSES THE PREVIOUS CRITERIONSUCH AS PRACTICAL ISSUES RELATED TO ISOLATING CANCER CARE EXPENDITURES, BUT THIS ALSO WILLCREATE SOME COMPLEXITY IN THE MODEL RELATIVE TO LOOKING AT COST OF CARE LIKE CURRENT MODELOUT THERE DOES.AND AGAIN HOW YOU ACTUALLY HANDLE THOSE DEVIATIONSFROM PATHWAY AT THE PRACTICE LEVEL AS WELL AS FEDERAL POLICY LEVEL HAS TO BE REALLY THOUGHTTHROUGH TO CREATE A SITUATION THAT’S FLEXIBLE, SIMPLE AND NOT OVERLY COMPLEX. WHICH Gets US TO FLEXIBILITY. WE LIKE THE ABILITY OF THESE EVIDENCE BASEDPATHWAYS TO CHANGE IN REAL TIME, TO BASICALLY LOOK AT THE FACT THAT NOT EVERYTHING IS GOINGTO BE ON THE PATHWAY AND BE ABLE TO FOCUS ON THAT. THERE MAY BE SOME BENEFIT THAT COULD HAPPENFROM MORE NUANCED PROCESS OF ACCOMMODATING DEVIATIONS FROM THE QUALITY MEASUREMENT PROCESS. IN TERMS OF UNDERSTANDING WHY SOMEBODY WENTOFF PATHWAY. IT’S NOT Actually CLEAR HOW THIS WOULD BE PUTINTO THE CURRENT MODEL. WE Speculate THIS HAS THE ABILITY TO BE EVALUATED, THEY WERE THE SUBMITTER WAS VERY ARTICULATE WITH RESPECT TO TYPES OF METRICS THAT COULDBE EVALUATED WITH RESPECT TO QUALITY OF CARE COSTS AND PATIENT SATISFACTION.AGAIN, AS OF YET UNDEVELOPED NATURE OF THEOPCs AND LINGERING CONCERNS WE HAVE IS REALLY RELATED TO THAT AND THEN THERE’S CONCERNSABOUT HOW WE WOULD USE THE OCM PATIENT COHORT AS A COMPARATOR, WHAT WAS PROPOSE, LET’S COMPARETO ONES IN THE OCM MODEL BUT PERHAPS THAT’S NOT THE BET COMPARATOR GROUP. THERE’S SIGNIFICANT INTEGRATION IN STRENGTHWITH RESPECT TO CANCER CARE.WE DO BELIEVE THIS IS MORE INCLUSIVE OF INDEPENDENTPRACTICES THAN PERHAPS THE CURRENT MODELS THAT ARE OUT THERE ARE. WE ARE SOMEWHAT CONCERNED ABOUT THE MODEL’SEFFORT TO DELINEATE CANCER AND NON CANCER CARE AS RELATED TO PAYMENT AND COMPLEXITYRELATED TO THAT AND, You are familiar with, BELIEVE THE EMPHASIS ON SPENDING AND GRANULAR DETAIL ONSPENDING IS GOING TO BE A REAL PLUS, AS CLINICIANS ARE ABLE TO SEE THE DATA, THE PUBLIC IS ABLETO SEE THE DATA AND COME UP WITH WAYS OF ACTUALLY IMPROVING ON THE EFFORTS THAT THEY HAVE. BUT ONE OF THE POTENTIAL CONCERNS IS BECAUSETHEY HAVE THE ABILITY TO EXCLUDE HIGH COST CLINICIANS THAT MAY NOT NECESSARILY GENERATEHIGHEST QUALITY TEAM OR EVEN OVERALL COST SAVINGS IS SOMETIMES HIGH COST PHYSICIANSARE HIGH COST BECAUSE MOST COMPLEX PATIENTS GO TO THEM.THAT HAS TO BE THOUGHT THROUGH. WITH RESPECT TO PATIENT CHOICE, IT’S EXPLICITLYSTATED PATIENT PREFERENCE FOR PROVIDER AND HOSPITAL WILL BE SOLICITED AND ACCOMMODATED. THERE WAS DESCRIPTION OF OTHER ASPECTS INTOINCLUDING APPLICATIONS AND THERE MAY BE, AGAIN, SOME BENEFIT FROM A MORE EXPLICIT OR DETAILEDSHARED DECISION MAKING PLAN AS PART OF THE MODEL. AGAIN, THERE WAS SOME CONCERN ABOUT THE CUMBERSOMEPROCESS OF SWITCHING OPC IF CANCER DIAGNOSIS OR PATHWAYS CHANGED AND IMPACT THAT MIGHTHAVE ON PATIENTS IF THAT OCCURRED. AND THEN THE PROCESSES FOR EXITING THE MODELWERE NOT FULLY DESCRIBED, WE ONLY GIVE 20 PAGES. WE’VE Get PLENTY OF OTHER TYPES OF INFORMATIONOUT THERE THEY WERE THINKING THROUGH THESE THINGS.WE THINK OF EVIDENCE BASED AS A WIN FOR PATIENTSSAFETY, AND WILL LIKELY YIELD IMPROVEMENTS FOR CLINICIANS WORKING TOGETHER TO COME UPWITH EVIDENCE BASED PATHWAYS, DATA CAPTURE WILL IMPROVE AS LEARNING OCCURS IN REAL TIMEAND TRANSPARENCY WILL AS WELL HEALTH INFORMATION TECHNOLOGY, FROM MACHINE LEARNING TO LOOKINGAT CLUSTERS AS IT RELATES TO THINKING ABOUT DEVIATION FROM THE PATHWAY. THAT’S IT. BRUCE, ANYTHING TO ADD? >> JUST ONE. YOU MADE IT CLEAR OUR PRINCIPAL RESERVATIONSHAVE TO DEAL WITH DEVELOPMENT OF OPCs. I NOTE IN THE RECENT RESPONSE TO THE PRT REPORTTHEY STATE ONCOLOGY PAYMENT CATEGORIES ARE NOT ONLY POSSIBLE BUT HAVE BEEN PRODUCED ANDCAN BE MODIFIED IN A TIMELY MANNER TO ACCOMMODATE CHANGES IN CARE.I’M LOOKING FORWARD TO HEARING MORE ABOUTWHEN DR. MCANENY AND TEAM APPROACH THE TABLE. >> I’M HOPING THAT THOSE OF THE DELIBERATIONSTHIS DAY WILL BE QUESTIONS THAT ARE DIRECTED AT APPLICANT RATHER THAN ME OR BRUCE OR THESPIRIT OF BOB. BUT IF WE HAVE ANY DIRECT QUESTIONS, THATYOU ALL NEEDED TO ANSWER RIGHT NOW BE HAPPY TO DO SO. >> LEN? >> I WAS Moving TO MOVE WE BRING UP THE PRESENTERS, YOU’VE DONE A FANTASTIC JOB, IT’S ALL ABOUT THE OTCs, LET’S PLAY THE GAME .>> DOCTOR, DR. MCANENY AND TEAM. >> IF YOU COULD Establish YOUR TEAM AND THENWE’RE GOING TO HAVE OPENING COMMENTS FROM YOU FOR TEN Instants AND THEN OPEN IT UP TOEXCHANGE BETWEEN THE COMMITTEE. THANK YOU, BARBARA. >> THANK YOU VERY MUCH. Commission members, I’M BARBARA MCANENY, PRACTICING ONCOLOGY IN NEW MEXICO, AMA PRESIDENT. AND I DID HAVE THE COME HOME INNOVATION CENTERGRANT. I’LL HAVE KAMERON INTRODUCE THEMSELVES ANDTERRILL AS WELL. >> Good morning, KAMERON BAUMGARDNER, CHIEFTECHNOLOGY OFFICER OF DATA SCIENCE AND ANALYSIS CONSULTANCY KNOWN AS RS2 1. >> Good morning, TERRILL JORDAN, PRESIDENTAND CEO OF REGIONAL CANCER CARE Identify OUT OF HACKENSACK, NEW JERSEY. >> MAKING THE NETWORKS IS THE NEXT STEP INTHE TRANSFORMATION OF ONCOLOGY Assistance FROM FEE FOR SERVICE TO ALTERNATIVE PAYMENT MODEL, IN NOVEMBER OF 2017 CMS REQUESTED PILOT PROJECTS TO BE SCARED ACROSS SITES AND SERVICE.MASON IS A PILOT USING A GROUP OF PRACTICESWILLING TO OPEN THEIR AMRs TO COMBINE WITH CLAIMS DATA USING ADVANCED DATA SCIENCE TOPROVE TO CMS AND ONCOLOGIES ACROSS THE COUNTRY WE CAN CREATE AN ADVANCED APM FOR ONCOLOGY. THE TRANSFORMATION BEGAN WITH IOBS CMMI AWARDCOME HOME WHICH SHOWED INDEPENDENT PRACTICES TRANSFORMED TO ONCOLOGY MEDICAL HOMES COULDINTERVENE EARLY IN THE TOXICITIES OF CANCER AND TREATMENT, AND AVOID HOSPITALIZATION. COME HOME PROVIDED PATIENTS WITH SERVICE IT’SDELIVERED BY THEIR DOCTORS’S PRACTICE, KEPT PATIENTS ABLE TO SPEND MORE TIME AT HOME RESULTINGIN HEALTHY SATISFIED PATIENTS. COME HOME ALSO SAVED A SIGNIFICANT AMOUNTOF MONEY PER PATIENT. HOWEVER, COME HOME LACKED A PAYMENT SYSTEMTO SUPPORT THE PATIENT Assistance THAT CONSTITUTE ONCOLOGY MEDICAL HOME. THE SAVINGS WHICH WERE CONSIDERABLE CAME FROMAVOIDANCE OF HOSPITALIZATION, BUT EXPENSES FELL TO THE PRACTICES WITHOUT THE REIMBURSEMENTPROCESS. A TEAM OF PHYSICIANS AND HEALTH ECONOMISTSFOR THE AMERICAN SOCIETY OF CLINICAL ONCOLOGY DEVELOPED A PAYMENT SYSTEM TO PAY MEDICALHOME COSTS KNOWN AS PATIENT CENTERED ONCOLOGY PAYMENT SYSTEM AND IS INCORPORATED INTO MASONWITH PERMISSION FROM ASCO, OCM IMPLEMENTED THE FIRST ATTEMPT AT PAYMENT SYSTEM ADDINGMEDICAL EXTENDED ONCOLOGY SERVICE AND SHARED SAVINGS MODEL.TO BECOME ADVANCED APM PRACTICES WERE WERETAKE TWO SIDED RISKS COMPARED TO TARGET PRICE, ONLY A THIRD OF PRACTICES HAVE SHOWN SAVINGSAND SO FAR NO PRACTICES HAVE ACCEPTED TWO SIDED RISK. MASON IS A MODEL BUILT ON FOUNDATION LAIDBY OCM TO SOLVE LACK OF ACCURACY OF THE TARGET PRICE, TWO INABILITY OF PRACTICES TO MANAGEENTIRE COST OF CARE, THREE, INABILITY OF THE OCM MODEL TO KEEP UP WITH THE RAPID TECHNICALADVANCES OF CARE INCLUDING NEW DRUGS. AND FOUR, THE LACK OF REALTIME DATA THAT ALLOWSPRACTICES TO MAKE MID COURSE CORRECTIONS IN CARE. AS SHOWN IN SLIDES 3 THROUGH 5 COST OF CAREVARIES FOR FACTORS NOT IN THE OCM MODEL AND R SQUARED COST WITH ONCOLOGY CARE MODEL TARGETS. 33. Rehearses WOULD BE IRRESPONSIBLE TO ACCEPTRISK BASED ON THESE TARGETS, BECAUSE THE POSSIBLE REQUIRED REPAYMENTS COULD EXCEED ABILITY OFTHE PRACTICE TO REPAY RESULTING IN PRACTICES LEAVING THE MODEL, DEPLETING INFRASTRUCTUREOF CANCER CARE BY GOING OUT OF BUSINESS, OR DOUBLING THE AMOUNT CMS PAYS FOR CARE BY SELLINGTO A HOSPITAL.WE ADDRESS EXCESS RISK BY HAVING NCCA NATIONALCANCER CARE ALLIANCE PRACTICE PURCHASE A CAPTIVE PRODUCT AT STOP LOSS INSURANCE, REMAIN ATRISK FOR QUALITY WITHHOLD, COST OF PRACTICE TRANSFORMATION AND PATIENTS SMALL ENOUGH TOHANDLE WITHOUT A CLAIM BUT PROTECTED FROM PRACTICE ENDING RISK. THE ENTIRE COST OF CARE WAS INCLUDED IN OCMBECAUSE OF THE INABILITY OF THE OCM MODEL TO SEGREGATE ONCOLOGY RELATED COSTS FROM OTHERCOSTS OF CARE, AND WE WILL Support A METHODOLOGY THAT WILL LEAVE ONCOLOGISTS AT RISK FOR ONLYTHOSE Payment RELATED TO CANCER. MASON REMOVES ALL DRUG PRICES FROM THE MODEL, AND REIMBURSES THE ONCOLOGY PRACTICE FOR THE INVOICE PRICES OF THE DRUG.THIS NOT ONLY REMOVES THE MAJOR REASON THATONCOLOGY PRACTICES WERE UNABLE TO HIT THE OCM TARGETS BUT REASSURES BOTH PATIENTS ANDCMS THAT DRUGS ARE NOT SELECTED FOR A BETTER MARGIN. OR AVOIDED BECAUSE THE NEW BETTER BIOLOGICSWOULD CAUSE TARGET TO BE MISSED. WE WANT A TRANSPARENT SELECTION OF DRUGS ANDNEVER WANT TO PUT A PHYSICIAN IN POSITION WHERE DOING THE RIGHT THING FOR A PATIENTCAUSES AN ADVERSE OUTCOME FOR THE PRACTICE. IT Too ELIMINATES THE CONCERN OF THE PRACTICETHAT A PATIENT WITH PREEXISTING CONDITION REQUIRE BIOLOGIC AGENT OR SERIOUS EXPENSIVECOMORBIDITIES WOULD ADVERSELY IMPACT THE FINANCIAL PERFORMANCE. WE Never WANT A Structure THAT PENALIZES DOCTORSFOR CARING FOR COMPLEX PATIENTS. QUALITY OF CARE CONSISTS OF CUSTOMER SERVICE, DELIVERING CARE THE PATIENT WANTS WHEN AND WHERE THEY WANT IT AND BY WHOM.AND TECHNICAL QUALITY, DELIVERING THE TREATMENTPLAN THAT OPTIMIZES THE GOAL OF PATIENTS. THE MEDICAL HOME PROCESSES HAVE BEEN SHOWNIN COME HOME TO GENERATE EXCELLENT CUSTOMER SERVICE RESULTING IN PATIENT SATISFACTION, SCORES IN THE HIGH 90 s. TECHNICAL QUALITY OF CARE CONSISTS OF THEPATIENT BEING OFFERED ALL OF THE OPTIONS FOR CARE THAT ARE APPROPRIATE WHILE AVOIDING INAPPROPRIATECARE. THE GOLD STANDARD FOR QUALITY IS THE NCCNGUIDELINE. WITH THE ASSISTANCE OF NCCN, MASON WILL HELPTRANSFORM THOSE GUIDELINES INTO PATHWAYS EMBEDDED IN THE PRACTICE CMR. ELECTRONICALLY PROVEN COMPLIANCE WITH THEPATHWAYS WILL INCLUDE FAILURE TO DELIVERY APPROPRIATE RARE AS WELL AS DELIVERY OF INAPPROPRIATECARE AND ACTUAL CAUSES FOR DEVIATIONS CAN BE BUILT INTO THAT SO THE PHYSICIAN IS NOTPENALIZED WHEN A PATIENT, FOR EXAMPLE, ELECTS TO REFUSE RECOMMENDED CARE.FOR EXAMPLE, IF A PATIENT WITH A RECTAL CANCERIS NOT OFFERED PREOPERATIVE RADIATION THERAPY OR RESECTION ONCOLOGY WOULD BE OFF PATHWAYUNLESS THE PATIENT REFUSES AND WOULD SACRIFICE QUALITY WITHHOLD. IF EXCESS IMAGING A OR INAPPROPRIATE CHEMOTHERAPYWERE DELIVERED THE ONCOLOGIST WOULD BE OFF PATHWAY AND QUALITY WITHHOLD WOULD BE RETURNEDTO CMS. Portion OF THE TECHNICAL QUALITY OF CARE IS THEPATIENT SAFETY COMPONENTS OF HAVING INFUSION FACILITY. CERTIFIED BY THE ASCO PROCESS THAT MEETS REGULATORYSTANDARDS, RADIATION FACILITY THAT’S ACR ACCREDITED, AND APPROPRIATE ACCREDITATION OF SURGICALSUITES AND HOSPITALS. AS THE DRUG MARGIN HAS BEEN USED TO PAY FORTHE INFUSION FEE WE’RE REMOVING THE DRUG MARGIN. FACILITY FEE WILL PAY FOR THE FIXED COST OFHAVING APPROPRIATE CERTIFIED INFUSION FACILITY.THE COST SHOULD BE THE SAME REGARDLESS OFSITE OF SERVICE. THE ONCOLOGY PAYMENT CATEGORY IS CREATED VIADATA SCIENCE TECHNIQUES, TARGET OPC AMOUNT IS VISIT TO PRACTICE AND CMS AS VIRTUAL ACCOUNT. EVERY NON DRUG CLAIM SPLITTED RELATED TO CANCERCARE SUBTRACTED FROM VIRTUAL ALLOWS PRACTICES TO MONITOR PATIENTS WITH INCREASED NEEDS ORPHYSICIANS USING EXCESS RESOURCE USE. I’M NOW Departing TO TURN THIS OVER TO KAMERONTO DEMONSTRATE THE OPC. >> THANK YOU. WE’VE CREATED PROOF OF CONCEPT TO DEMONSTRATEFEASIBILITY OF QUICKLY CREATING AND UPDATING MASON OPCs, USED CLINICAL AND DEMOGRAPHICDATA OF 2500 EPISODES, FED INTO AN ALGORITHM TO IDENTIFY INDIVIDUAL CLUSTERS.WE EXPANDED EACH CLUSTER TO VALUED SIMPLESET OF 5000, MONTE CARLO SIMULATION, ANALYZED CLAIMS OF THOSE SIMULATED EPISODES TO PRODUCEOPC COST CURVES. FOR THIS DEMONSTRATION WE SELECTED THREE BREASTCANCER CLUSTERS FOR FURTHER ANALYSIS. THESE THREE Collections WE CHOSE GROUPED EPISODESTHAT WERE PREVALENT WITH DUCTAL T1, T1 AND LOBULAR T1 TUMORS. YOU CAN Participate ANALYSIS IN SLIDES 8 13. ANALYSIS REVEALED UNEXPECTED RESULTS, LOBULARHISTOLOGY OF TUMOR HAVING GREATER IMPACT ON COST OF CARE THAN SIZE OF TUMOR DEMONSTRATINGWHY THE MASON MODEL IS MORE ACCURATE.WE ALSO USED THIS GROUP OF CONCEPT TO DEMONSTRATECOMPUTATIONAL FEASIBILITY OF CREATING AND UPDATING OPCs. WE WERE ABLE TO CLUSTER AND PRODUCE COST CURVESAND DETERMINED METHODS TO SCALE PERFORMANCE TO MILLIONS OF EPISODES. FIRST, INDEXING DATA SET INTO THE CLUSTERINGALGORITHM REDUCES COMPLEXITY OF THE CLUSTERING PROCESS, MEANING INSTEAD OF ADDING 25 COMPUTATIONSFOR EACH ADDITIONAL FIVE EPISODES, WE ARE ONLY CREATING ADDITIONAL 11 Computings. THE MORE COMPUTATIONALLY COMPLEX PROCESS ISACTUALLY THE CREATION OF COST CURVES FROM EPISODE CLAIMS. FRANKLY THOUGH THIS IS A COMMON PROBLEM INTHE FIELD OF BIG DATA ANALYSIS WITH NUMEROUS WELL SUPPORTED SOLUTIONS SUCH AS SPARK ANDCORY THAT CREATE PARALLEL PROCESSES WHICH DIVIDE THE WORK. RS21 HAS PROCESSED MANY TERABYTES OF DATAIN HUNDREDth OF A SECOND. THE WAY THE MONTE CARLO SIMULATION SELECTSCLAIMS ENSURES NON CANCER RELATED COSTS WILL NOT BE COMMON IN SIMULATED DATASETS. FURTHERMORE, SETTING BASELINES OF HCC DATAAND STATISTICAL MODELS SUCH AS ISOLATION FORESTS CAN FURTHER FILTER COSTS PRACTICES HAVE NOCONTROL OVER.WE APPRECIATE PTAC’S TIME AND ATTENTION ANDLOOK FORWARD TO ANSWERING QUESTIONS. >> THANK YOU. WE’LL NOW OPEN IT UP TO THE COMMITTEE TO ASKSPECIFIC QUESTIONS OF THE SUBMITTERS. BRUCE? >> SO LET ME GET THIS STRAIGHT. YOU HAVE DEVELOPED THE ONCOLOGY PAYMENT CATEGORIES, HAVE YOU DEVELOPED THEM FOR ALL THE CANCERS YOU PROPOSE TO INCLUDE IN THE MODEL? AND IF SO, OR EVEN IF NOT, IS THE METHODOLOGYAND/ OR THE CATEGORIES THEMSELVES PROPRIETARY OR ARE THEY AVAILABLE FOR USE BY OTHERS OUTSIDEYOUR ORGANIZATION? >> THE FIRST ANSWER IS NO, WE HAVEN’T GONETHROUGH THE PROCESS OF DOING IT FOR ALL THE SEVERAL HUNDRED TUMOR TYPES OUT THERE BUTOUR GOAL FOR TODAY WAS DEMONSTRATE THIS IS INDEED POSSIBLE. WE Employed THE CLAIMS DATA FROM THE COME HOMEPRACTICES THAT WE HAD PLUS THEIR CLINICAL DATA TO GENERATE THIS. AND JUST SELECTED THIS ONE AS A DEMONSTRATIONTO SHOW WE CAN DO IT.EQUIVALENTLY WE COULD Make THE CLAIMS DATAFOR COLON CANCER PATIENTS OR FOR PROSTATE CANCER PATIENTS AND CREATE THE SAME PROCESS. AND AS FOR THE PROPRIETARY NATURE, I’LL REFERTHAT TO KAMERON. >> THEY ARE OPEN SOURCE AND FREELY AVAILABLE. EXPERTISE IS COMBINING THOSE WITH BIG DATAAPPLICATIONS AND PROCESSING Service TO MAKE GENERATION OF THESE IN A TIMELY MANNER FEASIBLE. >> LEN. >> Expressed appreciation for FOR THAT. YOU MENTIONED THAT YOU HAD 2500 I Suppose PATIENTSFROM THE COME HOME AND YOU HAD THE CLINICAL DATA TO GO WITH THE CLAIMS FOR THEM.HOW MANY PATIENTS WOULD IT TAKE TO DO NOTALL THE CANCERS BUT SOME 25% OF ALL CANCERS OR SOMETHING TO CREATE A CRITICAL MASS OFOPCs FOR A LARGER RANGE OF CANCERS, HOW MANY MY CONCERN WOULD BE MEDICARE HAS LOTS OF CLAIMS, THEY DON’T HAVE EHR DATA. WHERE CAN WE GET ENOUGH EHR DATA TO REPLICATEWHAT YOU’VE DONE FOR COME HOME? >> SO, I HAVE TERRILL JORDAN HERE TO REPRESENTTHE NATIONAL CANCER CARE ALLIANCE. THIS IS AN Organization OF 16 Patterns, INDEPENDENTPRACTICES, COAST TO COAST, WHO ARE ALL ON THE SAME EMR ESSENTIALLY, THERE’S ONE OR TWOWHO ARE NOT, WHO HAVE ALL AGREED THEY ARE WILLING TO PARTICIPATE. SO, WE SEE ABOUT 75,000 NEW PATIENTS PER YEARHAVE ABOUT 500,000 Patients ON TREATMENT FOR VARIOUS TUMOR TYPES.SO, WITH ACCESS TO CLAIMS DATA, WHICH WOULDHAVE TO BE SUPPLIED BY CMS, THAT WE Speculate THAT WOULD BE SUFFICIENT NUMBERS TO GENERATEESPECIALLY FOR THE MORE COMMON CANCERS. AND DO YOU WANT TO COMMENT ON THAT? >> GIVEN INVOLVEMENT IN VALUE BASED ARRANGEMENTWE WRESTLE DATA WITH AVALANCHE OF DATA TO MANAGE CANCER CARE, WE’RE INTIMATELY ACQUAINTEDWITH NEED FOR ROBUST ANALYTICS. DEEPER INTEGRATION OF ANALYTICS INTO CLINICALPRACTICE IS A PRIMARY GOAL OF MODERN HEALTH CARE. DATA DRIVEN DECISIONS ARE FUNDAMENTAL PRACTICINGMEDICINE IN INCREASING COMPLEX ENVIRONMENT AND ESSENTIAL TO DELIVERY OF HIGH VALUE PATIENTCENTERED CARE. Physicians FACE THE LANDSCAPE EXPLODING REQUESTCHALLENGES AND FIND IT DIFFICULT TO DECIDE MOST FAVORABLE TREATMENT PLANS. THE PACE OF GROWTH MAKES IT DIFFICULT FORPHYSICIANS TO KEEP UP WITH LATEST CLINICAL RESEARCH. EVIDENCE BASED MEDICINE DRIVEN BY DATA ANALYTICSIS THE KEY TO PHYSICIANS MAKING SENSE OF ALL THIS MEDICAL INFORMATION. ADDITIONALLY PHYSICIANS IN THEIR CLINICALSTAFF MUST RECEIVE RELEVANT INFORMATION AT THE POINT OF CARE TO IMPACT CLINICAL DECISIONMAKING MOST DIRECTLY. THE RIGHT INFORMATION RECEIVED AT THE RIGHTTIME IS CRITICAL TO PATIENT CENTERED CARE.PHYSICIANS DESIRE INTELLIGENT DECISIONS SUPPORTWITH DETAIL THAT IS TAILORED TO ADDRESS SPECIFIC PATIENT NEEDS. AS SUCH, PRIVATE PRACTICE IS MUCH INTEGRATECLINICAL DATA INTO THE ENTIRE WORK FLOW TO REDUCE BURDEN ON PHYSICIANS, S IFS ABLE TOEXECUTE GUIDELINES WILL DELIVER MEANINGFUL QUALITY IMPROVEMENTS. IN ADDITION THE LARGER POOL OF PATIENTS ANALYZED, THE MORE STABLE THE CONCLUSIONS REGARDING THE GUIDELINES. THIS WILL ENABLE PHYSICIANS TO PROVIDE MOREEFFICIENT MEDICAL DECISIONS, YET PRIVATE PRACTICES ARE FACING EXTRAORDINARY ADMINISTRATIVE BURDENSAS BOTH GOVERNMENTAL AND COMMERCIAL PAYERS BEGIN SHIFTING FINANCIAL RISK TO PHYSICIANS. TO REDUCE UNNECESSARY TESTS AND PROCEDURESWHILE ENSURING QUALITY OF OVERALL PATIENT CARE PRACTICES WILL REQUIRE TECHNOLOGY TOMEET MINIMUM QUALITY METRICS FOR VALUE BASED CARE. HENCE TO ADEQUATELY PARTICIPATE IN RISK BASEDARRANGEMENTS, PRIVATE PRACTICES REQUIRE FULL SUITE OF DATA AGGREGATION, ANALYTIC CAPABILITIES, AND ACTIONABLE REPORTING ON BEHALF OF PHYSICIANS.PARTICIPATION IN A PROJECT LIKE MASON WILLALLOW PHYSICIANS TO WORK TOWARDS CENTRALIZED ANALYTICS, TOWARD A CENTRALIZED ANALYTIC DATABASEENHANCING PERFORMANCE REPORTING OF ALL THE PARTICIPATING PRACTICES. THIS WILL SIGNIFICANTLY FURTHER THE EVIDENCEBASED DECISION SUPPORT NECESSARY TO SUPPORT PHYSICIANS TO SUCCESSFULLY NAVIGATE MASONOR SIMILAR VALUE BASED PROGRAMS. >> CLEARLY THEY ANTICIPATED THE QUESTION. THAT WAS GREAT. YOU FIGURED THIS OUT. BUT WHAT I Require TO KNOW IS IF I HEARD THEPRT CORRECTLY, THEY ARE WORRIED ABOUT A TIME FRAME OF UPDATING THE OPCs, RECLASSIFYINGA PATIENT BECAUSE OF THE PARTICULAR PATHWAY, THEIR OWN DISEASE, YOU GET THE POINT. YOU TOLD ME YOU HAVE TO KEEP SENDING EQUATIONSTO HINTERLANDS SO DOCTORS CAN USE THE RIGHT ONE. WHAT’S YOUR IDEA OF TIME FRAME OF ADJUSTMENTS. >> Expressed appreciation for FOR THE CLARIFICATION. WE DEVELOPED PROOF OF CONCEPT TO ADDRESS SOMEOF THESE INITIAL QUESTIONS ABOUT THE FEASIBILITY OF QUICKLY UPDATING THIS DATA GIVEN CHANGINGIN COST STRUCTURE AND ADDING NEW PATIENTS INTO THE CLUSTERS. OUR INITIAL RESULTS AS I MENTIONED WERE ABLETO BE PRODUCED AND COMPUTED IN UNDER AN HOUR. WE Speculate THAT’S FEASIBLE TO SCALE UP TOLARGER NUMBERS OF CLAIMS .>> THIS IS DR. SINOPOLI. >> THAT I WAS Located ON 500. ON 500,000 IT CAN’T BE THAT QUICK. >> SO THERE ARE A FEW EMERGING TECHNOLOGIESIN THE BIG DATA ANALYSIS BASE THAT PARALLELS THE PROCESS I MENTIONED ALLOWS US TO HAVEHUNDREDS OF COMPUTERS WORKING ON THIS AT THE SAME TIME IN PARALLEL RATHER THAN HAVING ONEBIG MACHINE DEAL WITH IT. THAT’S THE OPTIMIZATION PROCESS WE’VE SUGGESTED, BASED ON OUR INITIAL DISCOVERY. AND WE Belief WE CAN Maintain THAT PERFORMANCELEVEL UP TO HUNDREDS OF THOUSANDS OR MILLIONS OF EPISODES. >> ANGELO, WE HEAR YOU. WE’RE GOING TO LET DR. MCANENY FINISH. >> ONE OF THE OTHER CONCERNS FROM THE PRTREPORT WAS THE CONCERN ABOUT SWITCHING AN OPC.SO IF THE PATIENT WERE TO SELECT FOR EXAMPLEA HIGH COST PROVIDER WHICH IS GENERALLY IN ONCOLOGY AN ACADEMIC SURGEON WITH SPECIFICEXPERTISE IN DOING SOMETHING OR PROTON THERAPY OR SOMETHING THAT IS NOT PROVIDED WITHIN APRACTICE, THEN THAT PATIENT WOULD BE REFERRED AND THAT WOULD BE THE ENDPOINT OF THAT OPCBECAUSE THAT PATIENT WOULD THEN NOT BE BEING MANAGED BY THAT PHYSICIAN. SIMILARLY IF A PATIENT COMPLETES THEIR BLOCKOF ADJUVANT THERAPY, THEY WOULD Intention THAT OPC AT THE END OF THAT TIME AND GO ON TO LIKEA MAINTENANCE OPC WHICH WOULD BE MUCH LOWER COST BECAUSE THEY ARE BASICALLY GETTING AFEW OFFICE VISITS AND MAYBE A FEW BASIC TESTS. IF THAT PATIENT WERE TO RELAPSE AT THE TIMEOF RELAPSE THE RESTAGING PROCESS WOULD THEN ASSIGN THEM TO A DIFFERENT OPC FOR METASTATICCANCER. TO CREATE VARIOUS OPCs NEEDS TO BE AN ITERATIVEPROCESS BECAUSE ANYTIME YOU FIX SOMETHING IN TIME AND SPACE, AND THEN MEDICAL SCIENCECONTINUES TO ADVANCE, PRETTY SOON YOU HAVE A SET OF TARGETS THAT DON’T REFLECT THE REALITYOF CANCER CARE.AND SO BY WORKING WITH THIS GROUP OF PRACTICESWHO HAVE AGREED TO OPEN THEIR EMRs TO SUBMIT ACCURATE DATA SO WHEN WE DISCOVER THINGS LIKELOBULAR BREAST CANCER IS DIFFERENT FROM DUCTAL BREAST CANCER, WHICH WAS A SURPRISE TO MEAS AN ONCOLOGIST OF 30 YEARS, I DIDN’T Belief THE COST WOULD BE DIFFERENT, THAT Conveys THATWE CAN THEN RETOOL AND HAVE THAT DATA SUBMITTED, AND THEN SEND IT TO THE DATA FEES AND COMPUTERTO BE ABLE TO UPDATE THAT ON A CONTINUOUS BASIS.SO PART OF THE TIME FRAME OF CREATING THEOPCs FOR THE REALLY COMMON CANCERS, THE ONES WHERE IT’S REALLY IMPORTANT TO HAVE AN EXACTTARGET, LUNG, COLON, BREAST, PROSTATE, For example, THERE’S SUFFICIENT NUMBER OF THOSEIN THE DATABASE OF THE GROUP OF PRACTICES THAT THOSE COULD BE GENERATED AS THE INITIALPART OUT OF THE CHUTE AND THEN MODIFIED AS SCIENCE CHANGES.IF YOU’RE LOOKING AT SOMETHING THAT’S VERYRARE, A MERKEL CELL TUMOR, FOR EXAMPLE, I’VE SEEN THREE IN MY CAREER WE MAY NOT NEED ANOPC EFFORT, MAY NOT BE WORTH THE TIME AND EFFORT TO COMPUTE AN AVERAGE PRICE FOR SOMETHINGTHAT’S EXCEEDINGLY RARE. DOES THAT HELP YOU? >> SO, DR. SINOPOLI IS ON THE PHONE, AND HE CAN’T SEETHE QUEUE. WE’LL TURN TO HIM AND THEN PAUL, JEN AND I’VEGOT A QUESTION.GO AHEAD, DR. SINOPOLI. >> I’M IMPRESSED WITH COMPREHENSIVENESS OFYOUR THOUGHT PROCESS AROUND THIS. ONE QUESTION. ARE YOU SUGGESTING THAT THIS BE A SINGLE NATIONALDATABASE THAT’S DRIVEN BY A MACHINE LEARNING AT THAT LEVEL, OR ARE YOU ENVISIONING THISTO BE MULTIPLE DATABASES THAT POP UP ACROSS THE COUNTRY DRIVEN BY MULTIPLE COGNITIVE COMPUTERPARTNERS ACROSS THE COUNTRY? HOW ARE YOU SEEING THIS SCALE OUT TO MOREAND MORE ONCOLOGY PRACTICES? >> SO I’LL START WITH THIS IS BARBARA ANDTHEN I’LL TURN TO KAMERON.WE WOULD START WITH THE IDEA OF A MODEL, BEFOREONCOLOGISTS WILL BE TRUSTING THAT THEY ARE WILLING TO ACCEPT TWO SIDED RISK BUILT INTOTHE PROCESS WE NEED TO BE ABLE TO DEMONSTRATE ITS ACCURACY. AND THEREFORE WOULD START AS A PILOT PROJECTUSING NCCA PRACTICES, AND DEMONSTRATE THAT. IN THAT SENSE IT’S THE ONE DATASET IN ONECOMMON DATABASE THAT WOULD GET Worked. THE CONCERNS THAT THE PRT SUGGESTED ABOUTARE WE USING THIS ONE GROUP AND THEREFORE THE TREATMENTS AND OUR SOMEHOW IDIOSYNCRATICIS ALLAYED BY USE OF NCCA GUIDELINES, A NATIONAL STANDARD OF CARE. KNOWN SCALE THIS IT COULD BE SCALED WITH I’LLLET KAMERON TO TALK ABOUT MULTIPLE COMPUTERS AND DATABASES WORK WITH THAT. BUT TO SCALE THIS THEN ONCE WE IDENTIFIEDTHE PROCESSES AND IDENTIFIED OPCs THERE IT WILL BE A LITTLE BIT LIKE TELLING ALL THEHOSPITALS IN THE COUNTRY THEY HAVE TO USE DRGs. THEY FIGURE IT OUT PRETTY QUICKLY. AND SO WE CAN HELP THEM AS WELL WITH HERE’SWHAT THE COME HOME PROCESSES ARE, THIS IS HOW YOU USE TRIAGE. WE’VE SEEN THAT HAPPEN THROUGH THE ONCOLOGYCARE MODEL.MULTIPLE ONCOLOGY PRACTICES HAVE REALLY SWITCHEDOVER TO EMBRACING ALL OF THESE PROCESSES THAT HAVE SHOWN TO IMPROVE CARE. ONCE WE PROVE IT THEN WE’LL BE ABLE TO ENCOURAGEONCOLOGISTS AROUND THE COUNTRY AND POSSIBLY OTHER ENTITIES, OTHER SPECIALTIES THAT AREMANAGING CHRONIC DISEASE WITH ACUTE EXACERBATION INTO USING THIS KIND OF A PROCESS. THE COMPUTING QUESTION >> YEAH, SO WE WOULD NEED TO EVALUATE THE POPULATION AS AN ENTIRE SAID.THE IMPORTANT THING TO NOTE THERE THOUGH ISGEOSPATIAL LOCATION IS TAKEN IN AS ASPECT WHEN WE’RE TALKING ABOUT WHAT ARE THE VARIABLESWE’RE LOOKING AT WHEN DETERMINING SIMILARITIES BETWEEN CLUSTERS. AS FAR AS THE COMPUTATIONAL FEASIBILITY OFSTORING DATA THAT LARGE, AS I MENTIONED, WE’RE EXPERIENCED IN THE USE OF DECENTRALIZED STORAGEAND COMPUTING SOLUTIONS THAT PREVENTS US FROM HAVING SINGLE SOURCE OF FAILURE, GEOSPATIALLYOR TECHNOLOGICALLY. >> THANK YOU. >> PAUL? >> THANK YOU.AND THANKS FOR BRINGING THIS FORWARD. THE FIRST QUESTION, I MIGHT BE SLOW, I Rationalize. WHEN BRUCE ASKED IS ANY OF THIS PROPRIETARYI WASN’T SURE I HEARD A YES OR NO. I HEARD FOLLOW UP. SO IS IT YES OR NO, IS SOME OF THIS PROPRIETARYOR NOT IF SOMEONE WERE TO PARTICIPATE? >> I CAN’T SPEAK TO THE DATA BUT THE ANALYTICALMODELS ARE NOT PROPRIETARY. >> SO NO IS THE ANSWER .>> NO. >> OKAY, GREAT. AND THEN SOME OF THE DISCUSSION MAKES ME THINKBACK TO HACKENSACK BECAUSE WE CAME FORWARD WITH CODA. I DON’T KNOW WHO ANSWERED. I’M CURIOUS HOW YOU COMPORT THEIR MODEL, ORWHAT THEY BROUGHT FORWARD WITH YOURS, IF YOU HAD ANY SORT OF REACTION TO THAT. >> WELL, REGIONAL CANCER CARE Associate ISA SEPARATE ASSOCIATION OH WE’RE NOT ACTUALLY PART OF HACKENSACK AND WEREN’T PART OF THATPRESENTATION. SO YOU’RE NOT FAMILIAR WITH THE CODA, FAMILIARBUT NOT >> I’M NOT ASKING YOU TO REPRESENT CODA NECESSARILYBUT JUST THINKING THEY WERE SORT OF USING ALGORITHMS TO BE MORE SPECIFIC AROUND THETHERAPY. I WOULDN’T Miss TO COMMENT ON SOMEONE ELSE’SMODEL BECAUSE I MIGHT SAY SOMETHING OUT OF TURN. >> ONE OF THE THINGS THAT I CAN SAY WITH THIS, WHEN I READ THE CODA BUT DON’T KNOW THAT MODEL SO WE DID NOT INCORPORATE THAT INTO THIS.ONE OF THE THINGS WE TRIED REALLY HARD TODO WITH THIS MODEL WAS TO BUILD ON CONSTRUCTS THAT ARE ALREADY IN PLACE, AND FAMILIAR TOCMS. CMS WOULD HAVE TO CONTINUE TO PAY CLAIMS INTHE USUAL FASHION, THEY ARE VERY GOOD AT DOING THAT. THEY CAN PAY FACILITY FEES, THE OPC WE FIGUREDWOULD LOOK AKIN TO A DRG OR APC. WE’RE TRYING TO USE CONSTRUCTS THAT WOULDBE MORE WITHIN THE COMPUTING NORMAL BUSINESS WORK OF CMS. AND SO THE CODA PROJECT SEEMED A LITTLE DIFFERENTTO ME FROM THAT. >> JENNIFER? >> THANK YOU VERY MUCH FOR YOUR PRESENTATION. SPECIFICALLY Expressed appreciation for FOR CREATING A MODELBASED ON DIGITAL HEALTH INNOVATION THAT CAN IMPROVE CARE DELIVERY SYSTEMS.I HAVE TWO QUESTIONS GERMANE TO CRITERIONTWO AROUND QUALITY AND COST. THE FIRST QUESTION IS AROUND WHO WILL BE PAYINGFOR ACCESS TO THESE PATHWAYS, AND THEN ALSO WHO WOULD BE PAYING FOR THE COST ASSOCIATEDWITH THE OPC ALGORITHM UPDATES? >> Expressed appreciation for. SO FOR THE ACCESS TO THE PATHWAYS, ONE OFTHE CONCERNS THAT I HAD HAD AT THE BEGINNING IS MOST OF THE PATHWAY VENDORS ARE PROPRIETARYAND DO CHARGE SIGNIFICANT AMOUNTS MORE THAN I CAN AFFORD IN MY PRACTICE TO HAVE THOSE. SO I REACHED OUT TO NCCN, WHO WAS THE SOURCEOF ALL OF THESE GUIDELINES, WHO ARE HERE TODAY TO COMMENT DURING THE PUBLIC PROCESS. NCCN IS OPEN SOURCED. THINK HAVING MEDICAL LITERATURE BECOME PROPRIETARYIS UNFORTUNATE AND I THINK THAT HAVING AN OPEN SOURCED PROCESS FOR THE BEST CARE ISTHE BEST WAY TO SPREAD THAT CARE ACROSS THE COUNTRY, SO WE’RE VERY MUCH LOOKING FORWARDTO HAVING NCCN WORK WITH US ON THIS.YOU KNOW, FOR THE COSTS OF DEVELOPING IT, ALL THE COSTS OF DEVELOPING ANY SORT OF A PAYMENT SYSTEM HAVE TO BE Entered INTO THE PROCESSOF THE PAYMENT SYSTEM. IF WE LOOK AT, For example, THE QUALITY WITHHOLDHERE OR WE’RE LOOKING AT COSTS NOW AN ACO USES TO CREATE MODELS, SAVINGS HAVE GONE INTOCREATING I.T. INFRASTRUCTURE FOR THOSE PARTICULAR MODELS. AND FRANKLY SOME OF THE PAYMENTS THAT WE WOULDBE GETTING WOULD BE ABLE TO BE FUNNELED INTO DOING THIS.WE HAVE TO PAY ALL THESE DATA GENIUSES TODO THEIR WORK. AND TO BE ABLE TO COME UP WITH THIS. SO THERE IS SOME INFRASTRUCTURE COST TO ANYPAYMENT MODEL. HOWEVER, HAVING IT BE ELECTRONIC AND HAVINGIT BE VISIBLE THROUGH THE CMS PROCESSES IS VERY APPEALING BECAUSE THAT’S SIGNIFICANTLYLESS THAN THE AMOUNT THAT WE PAY TO SUBMIT A CLAIM TO ANY OF THE COMMERCIAL PAYERS, ETCETERA. SO, I Believe THAT IT’S ONE OF THE Expenditures OFDOING BUSINESS. >> THANK YOU. MY SECOND QUESTION IS A PIGGYBACK ON A QUESTIONBRUCE ASKED BEFORE. THAT’S WHEN DESCRIBING THIS EPISODE OF ACTIVECANCER TREATMENT AND REMISSION, WHEN DOES THAT EPISODE END? AND A COROLLARY TO THAT IS WHY WERE OUTCOMESNOT DESCRIBED IN THE MODEL? AND THEN THIRDLY, THIS OPC ALGORITHM READJUSTMENTOBVIOUSLY SOUNDS LIKE IN YOUR PREVIOUS DESCRIPTION THERE WOULD HAVE TO BE ADJUSTMENT BASED ONACTIVE TREATMENT REMISSION, IF YOU COULD ADDRESS THAT RELATED TO THE QUALITY OF COST ISSUE .>> ONE OF THE Thwartings THAT WE HAD WITHTHE AS WE PARTICIPATE, STILL ARE IN THE ONCOLOGY TEAM, THE ONCOLOGY CARE MODEL, IS THAT NOTALL PATIENTS GET CHEMO. WE HAVE Cases PROSTATE CANCER PATIENTSWHO ARE MOST APPROPRIATELY WATCHFULLY WAITED ON.AND OBSERVED TO MAKE SURE THEY DON’T PROGRESS. BUT THEY Compel A FAIR AMOUNT OF EFFORT BUTTHEY ARE NOT IN THE MODEL. IF A PATIENT ONLY REQUIRES RADIATION THERAPY, EARLY HODGKIN’S PATIENT, FOR EXAMPLE, THE RADIATION ONCOLOGIST IS NOT IN THE MODEL, AND IN THIS MODEL ANY ONCOLOGIST COULD BE INITIATING CONSULTATIONS THAT WOULD STARTTHAT. AS YOU GO THROUGH THE NCCN GUIDELINES THEYARE SPECIFIC IN TERMS OF THE OPTIONS OF THERAPY AND OPTIMAL THERAPY. AND WE WOULD Employ INTO THE MODELS AND WE HAVEEMBEDDED INTO OUR ELECTRONIC MEDICAL RECORDS THE PATHWAY. THE PROCESS OF YOU NEED TO HAVE AN ECHO ATEVERY THREE MONTHS FOR IF YOU’RE GIVING SOMEONE HERCEPTIN, YOU HAVE TO HAVE VARIOUS TESTINGAT VARIOUS OPPORTUNITIES. BUT WE KNOW, FOR EXAMPLE, IN THE ADJUVANTSETTING THAT IT STARTS WITH THE FIRST PAYMENT, THE FIRST VISIT TO THE ONCOLOGIST, AND THERE’SA POINT WHERE ADJUVANT THERAPY IS COMPLETED.AND SO AT THAT POINT THAT PERSON WOULD BESWITCHED TO THE DIFFERENT ONCOLOGY PAYMENT CATEGORY. SO THESE EPISODES IN THESE EPISODES THAT WECREATE TIME IS JUST ONE OF THE VARIABLES. AND NOT THE DEFINING VARIABLE WHICH I THINKSTRENGTHENS IT. FOR OUTCOMES, I Contemplate PRODUCING REAL OUTCOMESDATA FOR THE FIRST TIME WILL BE AN INTERESTING BY PRODUCT OF THIS. IN THAT IF WE HAVE THE ABILITY TO TAKE A PATIENTWHO STARTS OUT WITH A GIVEN CHEMOTHERAPY REGIMEN OR GIVEN RADIATION REGIMEN OR ANY INITIATINGEVENT, WE WILL THEN BE ABLE TO LOOK OVER TIME AND SEE WHETHER OR NOT THEY ACTIVATE THE TRIAGEPATHWAYS MORE FREQUENTLY THAN A DIFFERENT REGIMEN WOULD HAVE THEM ACTIVATED. WE’LL BE ABLE TO HAVE THE INITIAL EVENT, MEASURETHE TOXICITY IN A VERY OBJECTIVE MANNER, AND AT THE END OF THAT EPISODE THEN WE WOULD BEABLE TO SAY WHAT THE OUTCOME WAS.OUTCOMES IN ONCOLOGY CAN TAKE YEARS. SO WE WOULD HAVE THE SHORT TERM OUTCOME OFHAVE YOU SUCCESSFULLY COMPLETED ALL OF THE ADJUVANT THERAPY AND HOW TOXIC WAS IT ANDTHEREFORE WHAT DO WE HAVE FOR TOTAL COST OF CARE AND BE ABLE TO DO OUTCOMES OF REGIMENA VERSUS REGIMEN B, INCREDIBLY VALUABLE HELPING ONCOLOGISTS UNDERSTAND WHEN WE’RE SELECTINGREGIMENS, SITTING DOWN WITH A PATIENT TO SAY IF YOU PICK THIS ONE, YOU CAN EXPECT THESETOXICITIES, IF YOU PICK THIS ONE YOU CAN EXPECT THESE OTHER TOXICITIES. I Envisage THAT WILL BE INCREDIBLY USEFUL TOONCOLOGISTS MOVING FORWARD TO BE ABLE TO BETTER HELP PATIENTS SELECT WHAT THEY WISH TO HAVE. YOUR THIRD QUESTION WAS SO WE WILL EVENTUALLYGET TO OUTCOMES. BUT OUTCOMES IN ONCOLOGY CAN TAKE YEARS TOREALLY DEMONSTRATE. BUT AS WE DEVELOP THESE EPISODES, THEY CANTURN INTO BUNDLES.AND THE EVENTUAL LONG TERM GOAL WOULD BE TOSAY I HAVE A BREAST CANCER PATIENT WHO FITS IN THIS OPC, LET ME HAVE THE BUNDLE AND GOAT RISK FOR THAT. THAT’S PAST WHERE WE ARE HERE. THAT WOULD BE THE NEXT PHASE. BUT I Consider THAT WOULD BE A VALUABLE WAY TOLOOK AT THAT. AS FOR THE OPC ALGORITHMS CHANGING WHERE YOUTALK ABOUT THE UPDATES OR SWITCHING FROM ONE TO THE OTHER. WELL, THE SWITCHING FROM ONE TO THE OTHERIS A CLINICAL DECISION. SO THAT WHEN A PATIENT ELECTS I’M GOING SOMEWHEREELSE, IT Discontinues. IF THE PATIENT COMPLETES THE COURSE OF THERAPYTHEY WOULD SWITCH TO MAINTENANCE/ OBSERVATION TYPE OF OPC. CLINICAL ENDPOINTS WE SEE IN ONCOLOGY ALLTHE TIME OF WHERE WE COULD DEMARCATE THAT. AS FOR THE CONSTANT UPDATING OF THINGS, ONCOLOGYIS VERY FLUID, AND ANY PAYMENT SCHEME THAT DOES NOT REFLECT THE ONGOING CHANGES THATARE OCCURRING WOULD GIVE US TARGETS WE CAN’T HIT. OR WOULD Devote THE ADVERSE INCENTIVES OF BETTERAVOID THAT PATIENT WITH PSORIASIS OR THIS EXPENSIVE DRUG OR COMORBIDITIES THAT WILLMAKE THEM MORE EXPENSIVE BECAUSE I WON’T HIT MY TARGET, WE NEED TO BE ABLE TO HAVE THISPROCESS TO SAY, OKAY, NOW WE HAVE THE OPC AND WE’VE LEARNED THAT DIABETICS WHO HAVETHIS PARTICULAR PROBLEM OR PEOPLE WITH FOOD INSECURITY WHO HAVE THIS PARTICULAR PROBLEMARE GOING TO COST AT A DIFFERENT LEVEL.AND WE WOULD BE ABLE TO GET INCREASINGLY GRANULARUSING THE DATA SCIENCE PROCESSES. DO YOU WANT TO COMMENT ON THAT? >> YEAH. ON THE FREQUENCY OF THE UPDATING SPECIFICALLY, THAT PROCESS WOULD NEED TO BE TRIGGERED ANYTIME THERE’S A SIGNIFICANT CHANGE IN THE DATA BEINGINTRODUCED, SO ANY SHIFT IN PAYMENT STRUCTURE OR COST. IT WOULD NEED TO CHANGE WHEN WE GET A STATISTICALLYSIGNIFICANT NUMBER OF ADDITIONAL CASES, THAT NUMBER WILL CHANGE AS OUR POPULATION SIDEGETS LARGER. SO ADDING TEN EPISODES INTO OUR SET THAT WE’REEVALUATING IS LESS IMPACTFUL AT 500,000 Contingencies THAN 500. WE WOULD BE ABLE TO EVALUATE THAT AND TRIGGERIT DYNAMICALLY BASED ON THE SIZE OF THE SETS AND DATA WE’RE SEEING. >> Expressed appreciation for. THANK YOU FOR YOUR PROPOSAL AND ALL OF THEWORK THAT YOU’VE DONE WITH THE COMMITTEE TO ANSWER ALL OF OUR QUESTIONS. I HAVE ONE QUESTION THAT COULD BE CLARIFIED.IN THE PROPOSAL YOU CALL OUT UNDER THE QUALITYSECTION THAT THE EVALUATION PROCESS WILL BE DONE BY THE INNOVATIVE ONCOLOGY BUSINESS SOLUTIONSAND SELECT CONTRACTORS. SO MY QUESTION IS, IS THE MODEL RELIANT ONTHE INNOVATION ONCOLOGY BUSINESS SOLUTIONS OR COULD THERE BE ANOTHER ENTITY THAT PROVIDESTHAT BACKSTOP? I’M CURIOUS. I DON’T Require TO SAY PROPRIETARY BUT WHAT’STHE RELIANCE ON THAT INTELLECT IN THIS MODEL ITSELF? >> ACTUALLY I WOULD Elevate TO HAVE THAT BEEVALUATED BY OTHERS. WE Wreaked WHEN WE HAD THE COME HOME GRANT, WE WORKED VERY HARD TO MAKE SURE THAT WE SUPPLIED ALL OF THE DATA TO THAT. SO I Inspect AT THE ROLE OF IOBS WHICH WOULDHAVE TO BE RECONSIDERED BECAUSE IT DOES NOT CURRENTLY HAVE THE PEOPLE NEEDED TO MANAGETHE 16 PRACTICES PRODUCE THE DATA. SO, WHAT I WOULD Elevate WOULD BE TO HAVE ANEXTERNAL PROCESS THAT EVALUATES MUCH AS HAPPENED WITH COME HOME, AND WE WOULD BE THE DATA SUPPLIERSTO THE EXTERNAL PROCESS. >> OKAY. WHAT YOU’RE SUGGESTING IS IDEALLY YOU PREFERTHAT THERE BE A DIFFERENT INFRASTRUCTURE SETUP TO PROVIDE THAT INPUT AND TAKES IOBS OUT OFIT TO A LARGE DEGREE, IS THAT >> YES.I WOULD Make SO. IT’S NOT IDEAL I THINK TO HAVE THE PERSONWHO IS MANAGING THE MODEL ALSO EVALUATE. IT’S BETTER TO HAVE EXTERNAL EVALUATION. >> THAT WAS MY QUESTION. THANK YOU. >> BRUCE? >> THANK YOU FOR ALL THIS HARD WORK. I’VE BEEN SITTING HERE LOOKING AT VERY SATISFYINGSLIGHTLY SKEWED TO THE RIGHT CURVES. IF WE ACCEPT YOU HAVE INDEED DEMONSTRATEDPROOF OF CONCEPT, AND THAT’S SOMETHING THAT IS DISCUSSION AMONG COMMITTEE MEMBERS, IFWE ACCEPTED FOR THE SAKE OF ARGUMENT, WHAT NEXT STEPS WOULD NEED TO BE ACCOMPLISHED INORDER TO ACTUALLY HAVE WHAT’S NECESSARY TO IMPLEMENT THE MODEL? >> SO, IN ORDER TO IMPLEMENT THE MODEL, ONEOF THE THINGS THAT WOULD BE INCREDIBLY USEFUL WOULD BE TO HAVE ACCESS TO MORE CLAIMS DATAFROM CMS BECAUSE THE MORE DATA WE HAVE TO START THE FASTER WE CAN GENERATE THESE. AND SOME Is necessary to, You are familiar with, NOT EXCESSIVEAMOUNT OF TIME AS KAMERON SAID BUT TO BE ABLE TO PULL THE DATASETS TO LOOK AT THE VARIOUSTUMOR TYPES AND GENERATE THE IMMEDIATE PROCESS. WE HAVE Patterns WILLING TO WORK WITH THATSO WE’LL HAVE AN INTERNAL VALIDATION KIND OF PROCESS .>> THAT DOESN’T SOUND LIKE A WHOLE LOT. IT DOESN’T SOUND LIKE WELL, HOW MUCH TIMEDO YOU THINK IS INVOLVED IN THAT? >> FROM ANALYTICAL PERSPECTIVE WE CAN DO THISVERY, VERY QUICKLY. ORDERS OF MAGNITUDE THAT PROBABLY AREN’T RELEVANTFOR THIS DISCUSSION. THE PROCEDURE PART IS WHERE WE NEED TO SPENDTHE TIME. >> ALL RIGHT. WE’RE GOING TO OPEN IT UP, FIRST OF ALL, AGAIN, Expressed appreciation for. AND YOU GUYS ARE NOT GOING AWAY. YOU’RE JUST MOVING AWAY FROM THE TABLE. YOU’LL BE HERE FOR THE FULL DELIBERATION ANDDISCUSSION ..
