Collaborative Oncology Management Programs Could Save Costs and Improve Care

Atlanta—Innovative approaches to oncology management and collaboration with providers may be viable solutions for health plans to save costs and improve clinical outcomes for cancer patients. Three national health plans shared their approaches to oncology care during a Contemporary Issues session at the AMCP meeting. During the session titled Innovation That Drives Quality Wins in Oncology Care: Perspectives from Three National Health Plans, presenters discussed providing pathways of care for oncologists, building partnerships with physicians, and allowing for individualization in treatment. Phil Miller, director of pharmacy ancillary services for CareFirst BlueCross BlueShield, said the incidence of cancer continues to rise, while the cost for caring for these individuals is increasing. These rising costs can be attributed to an increase in the number of uninsured Americans as well as a growing number of biotechnology cancer medications in development. Mr. Miller highlighted a 2009 study that found that the total projected cancer incidence is expected to increase approximately 45% from 2010 to 2030. States across the country are showing high cost variability in Medicare spending to treat these patients, without better outcomes, he said. CareFirst BlueCross BlueShield developed an oncology management program to encourage compliance to pathways for breast, lung, prostate, hematologic malignancies, and colon cancers. The program, which is managed by P4 Healthcare, began in 2008 and is a pay-for-quality design. In the second year of the program, 100% of participating practices achieved the 80% compliance thresholds for both treatment and supportive care pathways. In addition, in 24 months, CareFirst BlueCross BlueShield saw a total of $17,203,405 in breast, colon, and lung savings. Mr. Miller said advances in science will continue to drive higher oncology costs, and pathways will likely be used to increase the use of generics. Pay-for-quality and medical home models, he said, may be a viable way to improve clinical and financial outcomes in oncology care. A second-generation version of their oncology management program addresses the whole oncology patient through treatment pathways, includes the incorporation of nonmedication services such as radiology, incorporates end-of-life services, and tries to remove the potential influence of drug reimbursement. Practices review charts monthly and are able to view meaningful data through a Web portal that compares physicians to the practice and the practice to the overall program. James R. Lang, PharmD, MBA, vice president of pharmacy services for Blue Cross Blue Shield of Michigan, also spoke about oncology management and said there are several large and long-standing Blue Cross Blue Shield programs in Michigan, including provider incentive programs, hospital incentive programs, collaborative quality initiatives, and patient-centered medical homes. The organization’s value partnerships strive to improve the quality of care through collaboration between the payer and the provider, and center on designing and executing programs that are customized. Through the partnerships, Blue Cross Blue Shield of Michigan rewards improvement, not just the highest performance. They also focus on long-term changes in care processes and use population-based cost measures rather than per-episode costs. As part of the value partnership program, they launched the Michigan Oncology Treatment Pathways Program in 2010, which is a partnership between Blue Cross Blue Shield of Michigan, the state’s oncology community, and P4 Healthcare. A steering committee of Michigan oncologists helped create clinical pathways for oncology treatment. According to Dr. Lang, these pathways establish the most up-to-date and effective treatments. Participating providers are expected to meet a 70% compliance threshold with the pathways in the first year the pathway is in effect and an 80% compliance threshold in subsequent years. The pathways were created to increase consistency in treatment regimens among providers and improve the overall quality of healthcare delivery. According to Dr. Lang, the program is not intended to replace clinical judgment and is regularly re-evaluated as new research is available. In the first year of the program, Dr. Lang said there were consistent and high levels of compliance across all pathways. By the end of the first year, a trend toward cost-savings was also beginning to develop. Physicians who participated in the pathways program were given incentive payments to encourage their participation, starting with a flat fee plus enhanced fees on several J codes for intravenous chemotherapy and supportive care drugs in the first year of participation. In the second year, providers receive a 10% uplift on the evaluation and management codes plus enhanced fees on several J codes. Dr. Lang also spoke about the company’s generic incentive program, which attempts to take the drug margin out of clinical decision-making and drive the use of generic treatment regimens. He concluded by saying that focused incentives, in addition to collaboration between providers, could be an effective way to drive change. Finally, Robert Wanovich, PharmD, vice president, market strategy and delivery, Highmark, Inc, spoke about Highmark’s oncology management program. The goals of the program were to promote the most effective therapies, limit unnecessary toxicity, provide treatment options to meet the majority of the patient’s needs, avoid unproven therapies, and maintain consistency with medical policy and formulary programs. The program was rolled out in 3 phases: filing and approval of the new reimbursement methodology (February-April 2011), communicating and recontracting with participating practices (March-June 2011), and implementing the new reimbursement plan as well as compliance monitoring (July 1, 2011). The next steps, Dr. Wanovich said, are to assess the program following 2 full measurement periods, add additional diagnoses to the program, and test additional reimbursement models that include non–drug-related services such as radiation, surgery, and palliative care.