Optimizing Oncology Care in Older Adults

Kjel A. Johnson, PharmD, arrived at CVS Health with a mandate to “fix cancer.”

So began the Vice President, Specialty Product Strategy CVS Health, in his 2022 Oncology Clinical Pathways Congress presentation, “Pathways to Optimize Care in Older Adults with Cancer.”

The mandate was not to fix cancer from a clinical perspective, Johnson said, but from the operational and integrational perspective.

“And it’s a mess,” he said. “We do a great job in the clinical part, but organizing patients and walking them through the journey probably needs some help.”

Johnson met with a physician team member to identify the problems in health care.

“If you want to know what the problems with health care are, go to the physician and walk through where the breakdown is,” Johnson said. “We found 13 key breakdowns. Screening clearly was one of them, sequencing was a problem. We looked at site of care.”

They also discovered that concordance with NCCN guidelines across the entire cancer population was coming in at around 75% across the country.

“We have 22 million patients … so we have the ability to really look across the country and see what concordance might look like,” Johnson said. “And it’s not good. I think most clinicians and experts would tell you that somewhere in the mid-90s is where you want to be.”

Having prior authorization as a part of CVS Health, Johnson and company sought a way to make it easy. The company bought an online prior authorization tool that integrates with NCCN directly. The benefits are immeasurable.

“NCCN has 500-plus different modifications to their guidelines per year,” Johnson said. “When that change is made, almost instantaneously it’s updated in our system.”

CVS Health also uses a regimented drug approval process, so if a physician picks an NCCN regiment, it is automatically approved.

Johnson then shifted focus to the NCCN concordance surveys that CVS Health conducted and how it led to cost improvement and concordance in the elderly population. A model was created to predict which physicians were going to be concordant, and a study was run on patients receiving cancer treatment and primary care doctors.

For those with breast cancer, Johnson’s group looked at about 300 concordant and 300 nonconcordant patients broken down into those who were commercial fully insured, commercial self-insured, or belonged to Medicare.

“Across all different types of business, the concordant patients were about $5,000 to $7,000 less costly than nonconcordant patients,” Johnson said. “This is 25% to 50% less costly. Pretty impressive.”

In colon cancer, similar reductions in cost were seen among the commercial self-insured and Medicare patients, though costs for commercial fully insured patients were nearly identical for both concordant and nonconcordant patients.

For both prostate cancer and non-small cell lung cancer, more than 30% reductions in costs were seen for concordant Medicare patients compared to nonconcordant patients.

“So why were those patients who were concordant less costly than the nonconcordant?” Johnson asked. “It wasn’t that (the nonconcordant patients) were using the wrong [medications], they were getting [medications] they didn’t need. Four-fifths of the time, the reason they were more costly was that they were getting drugs they should not have received.”

Johnson then explained how a health plan can help optimize concordance.

“We have that auto approval system, NCCN, and integrated with our Novologix approval system,” Johnson said. “Once we put this in place, with NCCN, by regimen, we had 83% automatically improve, and once our staff medical oncologists reached out and talked to their peers, 100% of patients were NCCN concordant. So this is an interesting system. We’re not using prior auth as a cudgel, we’re using it as a trigger to have a peer-to-peer discussion.”

From there, CVS Health used 44,000 patients (26,000 of whom use Medicare) and predicted which types of practices and physicians would be concordant based on variables such as hormone therapy, patient age, race, gender, and others.

This was followed by a survey to figure out why patients end up at a particular oncologist. The top reason was primary care referral (42%). Selecting the doctor who confirmed the diagnosis was 33%, followed by assigned by hospital (29.5%), internet research (25%), distance from home (23.2%), recommendation from family/friend (17.9%), and other (2.7%).

The doctors were asked the same question. Same health system came in at 67.9%, followed by networking (39.6%), personal communication (30.2%), colleague in medical school/residency (28.3%), and other (5.7%).

“In summary, in the elderly, we know that concordance is a good thing,” Johnson said. “We also found that the average cancer patient costs $70,000 on average, but Medicare patients’ costs are less, and I would have expected more. Our thesis on that is that the physicians aren’t as aggressive in treating the Medicare patient as they are in the commercial patient.

“But we’re firm believers in NCCN concordance. I think what we’ve set up, rather than cudgeling doctors with onerous prior auth faxes, were doing it through an NCCN concordance, real time, then peer review is the way to go.”