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Challenges in Oncology Care Management
Managed care organizations (MCOs) identified the top challenges facing cancer care today in a recent report from Genentech.
According to the more than 100 MCOs surveyed for The 2015 Genentech Oncology Trend Report, balancing treatment standardization with personalization, advance care planning, and developing an equitable provider payment alternative to fee-for-service are currently the most pressing challenges in oncology. The trend report—which also surveyed specialty pharmacies (SPs) (n=30), oncologists (n=200), oncology practice managers (OPMs)(n=198), and self-insured employers (n=201)—also examined cancer drug management, oncology practice drug spending, cancer drug coverage and access, oncology practice trends, and population management. According to the report, the percentage of MCOs using guidelines and pathways to direct cancer treatment is on the rise. In 2014, 79% of those surveyed reported using guidelines for cancer treatment, a figure up from 74.8% in 2013. Just under half (40%) reported using pathways to guide care in 2014, up from 31.1% in 2013. The use of guidelines and pathways is greatest when treating breast, colorectal,
prostate, or lung and bronchus cancer. Oncologists themselves also reported high usage rates of guidelines and pathways. According to the data, 64.5% reported that they were currently using guidelines and an additional 5.5% said they planned to use them in 2015. Half also reported currently using pathways to guide treatment, with another 10.5% planning to use them in 2015.
Payers are using incentives to encourage the use of guidelines or pathways by offering faster processing of prior authorizations, expedited reimbursement processing, reduced prior authorization and precertification requirements, improved drug reimbursement, or bonus payments.
DRUG MANAGEMENT TRENDS
The report also looked at cancer drug management trends. For instance, the top integrated payer/ provider initiatives reported by MCOs were measuring the cost-impact of all treatment pathways, adopting patient-centered medical homes (PCMHs) across the provider network, measuring the clinical impact of treatment pathways on patient care, and implementing new risk arrangements and payment models with oncology practices.
Of those MCOs (n=31) who adopted PCMHs, most (90.3%) organized the PCMHs around primary care physicians, while 35.5% reported organizing them around oncology specialists. An additional 12.9% reported organizing them around nononcology specialists and 9.7% reported organizing them around a noncancer disease focus.
According to the presentation, MCOs are also using new provider payment models. While 12.4% say they are using value-based or quality initiatives, an additional 20.0% have pilot programs underway and another 33.3% say that initiatives are under investigation. Similar trends can also be seen in the use of global payments and risk sharing.
When it comes to oncology practice drug spending, 62.7% of those OPMs surveyed believed their drug expenses would increase in 2014 compared to 2013. However, 15.3% predicted a decrease in drug expenses pointing to lower patient volume, more commercially insured plans, more treatment outsourcing to hospitals and more white bagging, or getting patient-specific drugs directly from specialty pharmacies for in-practice use, as some of the factors leading to the decrease.
When asked about top pressing challenges facing cancer care today, 73.3% of SPs, 64.1% of OPMs, 51.5% of oncologists, and 40.8% of employers selected escalation in patient out-of-pocket costs as 1 of the top 3 challenges.
According to the presentation, MCOs are also forecasting increased oncology drug cost sharing in 2015. The report also addressed access concerns. The largest group of oncologists (49.7%) reported that drug shortages within the last 12 months had no change in terms of their economic impact on the practice, however, 45% did report an increased clinical impact. Reorganization is also underway as health care continues to evolve. Based on findings discussed during the presentation, many OPMs either have plans to or have already combined with other practices, integrated, or taken on a joint venture with a hospital or sold their practice to a hospital.
The survey also looked at ways that MCOs help direct care to the most cost-effective use of service. During the presentation, Genentech highlighted some of the responses from MCOs and grouped the responses into 4 categories: utilization management, oncologist reimbursement, member awareness, and contracting.
MCOs are using utilization management strategies such as creating site-specific rules for services or conditions, using prior authorizations to direct care to the lowest cost site of care, creating drug lists for medications that can be self-administered or taken at home, and promoting community care settings over academic facilities.
Some of the strategies around oncologist reimbursement include increasing the reimbursement rate for the administration of medications at the practice rather than in a hospital, participating in risk sharing arrangements with providers, and setting reimbursement rates at the specialty pharmacy rate for those drugs that are administered by physicians.
Some MCOs are also using techniques to improve member awareness, whether it’s by encouraging members to choose the least costly option or using case management referrals to ensure the lowest cost site is used.
Contracting is another strategy being used in practice. MCOs report implementing narrow or preferred networks, creating outpatient infusion clinics, or trying to move care away from the outpatient hospital setting.
PHARMACOECONOMICS
With recent advances in precision medicine, MCOs are adopting new ways to manage molecular and biomarker testing. For instance, 45.7% of MCOs reported that new molecular or biomarker tests sometimes triggered a Pharmacy & Therapeutics committee or coverage review of cancer medications and 26.7% say prior authorization is necessary before the use of biomarker testing. Additionally, 34.3% say they are in the early stages of developing a strategy to manage testing platforms and laboratories.
POPULATION MANAGEMENT
One of the final areas discussed during the session was population health management. According to the findings of the report, almost 4 in 10 employers now offer population health management programs. Of those who do, 72.2% reported offering a cancer program in 2014 and an additional 8.9% said they planned to have a program in 2015.
While more employers are adopting these type of programs, only 20% of cancer programs included health care consumerism, quality, and cost transparency tools.
Employers also reported a growing interest in encouraging participation in these programs. For instance, 78.9% were more inclined to offer a financial reward for participation than they were just a year before and 49.1% were more inclined to impose financial penalties than they were a year earlier.
According to data from the report, 67.2% of employers surveyed use health risk or well-being assessments as part of their overall health benefit strategy.—Jill Sederstrom
