The Lynx Group

Payer Trends in Oncology: Challenges and Solutions

July 2011, Vol 2, No 4

Philadelphia, PA—As the cost of cancer care continues to rise, payers are struggling with solutions to curtail the cost trend while maintaining value. This was the topic of the preconference session, which opened the 2-day First Annual Conference of the Association for Value-Based Cancer Care on March 29, 2011.

The cost of cancer care is on everyone’s front burner, said moderator Burt Zweigenhaft, BS, President and Chief Executive Officer at OncoMed, Great Neck, NY. “We’ve seen the average cost per cancer patient go from $53,000 [in 2005] to $115,000 [in 2010],” he said. “That’s unsustainable. That’s why it’s on everyone’s radar.”

Employers Looking for Value
Employers are increasingly asking about the value received for their money spent on cancer care, said Mona Chitre, PharmD, CGP, Director of Clinical Services, Strategy and Policy, Excellus Health Plan, FLRx Pharmacy Management, Rochester, NY.

“They are asking, ‘Are my patients living longer, am I reducing medical costs? What am I getting for $30,000 a dose?’ That’s difficult for us to articulate,” Dr Chitre pointed out. In western New York, considerable cost-shifting to the member is taking place, and payers are increasingly favoring generics.

“The decisions that are occurring with small, medium, and large employ ers are impactful to our patient population because of cost and our inability to articulate value,” she said.

Oncology Coverage Decisions
Actuarial predictions have long been the basis for adjusting premiums, said Scott Breidbart, MD, Chief Medical Officer at Empire BlueCross BlueShield, NY, but limits to premium increases are directed by government regulations. “So we’re not in a position where we can match our prediction. We know this is our only shot, because we’re all worried about what’s going to happen if we can’t keep costs down and how much government intervention there will be.”

Everyone is feeling the pressure to control costs, including employers, patients, providers, and the health plans. “The bottom line is that even members are concerned about the cost,” noted Maria Lopes, MD, Chief Medical Officer at AMC Health, Cresskill, NJ. “A great example that a provider shared with me recently is Provenge [sipuleucel-T vaccine for the treatment of advanced hormone therapy–resistant prostate cancer]. Mem bers are actually concerned about the cost, outcome, and value. We’re in a world where overall survival and treatment options are at the forefront.”

A major dilemma for payers is that cancer therapy cost remains at their risk. Cancer therapy risk or control is 100% covered under medical or Medicare Part B benefits. Chemo ther - apy drugs remain in the medical coverage based on coverage rules if a drug is “incident to physician visit/service under Medicare Part B or in a commercial payer world under medical benefit designs,” said Mr Zweigenhaft.

“Increasingly, all of the control and spending for cancer is on the medical side,” he said. “Does anyone have good data? When it’s in the medical side, it’s buried under J codes and nondescriptive codes. How do you manage something as a payer when you don’t have good data?”

“Even when we have the data, we don’t have staging data that’s so critical from an actuary perspective,” responded Dr Lopes. “For new drugs, we have trained people who look at J codes. From 5 years ago to today, we’ve made tremendous progress. Our oncologists are on board, and it’s actually become a very collaborative environment in that they want to make sure that they get paid and they follow the rules of the health plan.”

Coverage: Cost versus Evidence
One criticism of coverage decisions regarding cancer care is that such decisions do not seem to adhere to the evidence base. In some cases, it becomes futility care.

“From the pharmacy perspective, we’re seeing payers pay more attention to cancer care and what products are being used,” said Nick Calla, RPh, Vice President, Trade Relations, Specialty Pharmacy at Walgreens, Carnegie, PA.

“We’re starting to see a trend toward more visibility and more management in this space.” Mr Calla noted that, “The use of clinical pathways in oncology is increasing. With that said, cancer does receive special treatment to some degree, but we’re trending away from it.”

The challenge to payers is that “we’re seen as all about saving money. It’s not about evidence,” said Dr Lopes. “I think we often do sell hope and not science. A great example is resource utilization in the last 30 days of life, and how much cancer care we provide in the last 10 days of life. Maybe we should think about palliative care, which some evidence suggests may have additional benefit in terms of survival.”

More successful partnerships with physicians, who are in a position to have critical discussions around “end of life” with the patient, would help, she said. Such discussions should occur much earlier in the continuum of care and should take the direction of informed consent regarding treatment options and risk versus benefit to allow patients to make better decisions.

Cancer Drugs Price Spurs Debate
The price of drugs continues to spur cost debates. In the case of metastatic melanoma, the newly approved drug ipilimumab (Yervoy) costs $120,000 for a complete course of therapy, or $1 billion in new costs to payers. One randomized clinical trial showed that patients treated with ipilimumab had a median of 10 months overall survival compared with 6.4 months overall survival for those in the placebo-treated group, an almost 4-month advantage with this drug; furthermore, 20% of the ipilimumab-treated patients had 2 years of overall survival.

Unfortunately, “we don’t have a genetic marker to predict who benefits,” said Dr Chitre. “From the insurance perspective, we can’t make our decisions based on value. We have to make our decisions based on evidence. The concern becomes how we are going to determine our premiums based on drugs like that, and the potential population, when we don’t know staging from our own medical claims.”

Ipilimumab will be a “buy and bill” product for the next several years, which is managed through the medical benefit at the doctor’s discretion, with a slow evolution toward a more tightly managed product, advised Mr Calla.

Is Risk Sharing a Viable Option?
In Europe, 54% of oncology drugs are under risk-based contracting, said Mr Zweigenhaft.

Dr Lopes said that although such a contract might work in a single-payer system, it is not practical in the United States, where members move from one carrier to another. In addition, “we don’t always agree what constitutes success, much less what constitutes failure. How are we going to align agendas if we can’t define what outcomes look like?”

“I don’t think that risk sharing will work in the United States,” said Dr Breidbart. “If we have to look at every claim and ask if it’s medically necessary, that’s where you get disagreement, controversy, and contention.”

The amount of time, effort, and expertise involved would make risksharing rebates prohibitive, and “by the time we get the money back, if we do, who does it go to: the patient’s current employer, the last employer? Right now, there’s a lot of pressure on payers not to spend money on administrative costs, and this would be an administrative cost…to determine if the drug worked,” Dr Breidbart added.

Rebates and shared differentials may be practical in instances of competition, where multiple oral options exist for treating a certain cancer, said Dr Chitre.

Clinical Guidelines

Mr Zweigenhaft returned to the theme of futile care and the opportunity it presents to reduce variation in care and control costs through better adherence to clinical pathways. During salvage therapy, “we throw everything at them [the patients],” he said. “We seem to bombard them at the end of life. The final dose can be 3 times the cost of the first-line therapy, yet we have no outcomes.”

Dr Breidbart cited evidence that institution of hospice care prolongs life, although care may become less aggressive. “It does not surprise me that one can extend life by reducing unnecessary or unproven care,” he said.

“The difficulty is that we as physicians like to help our patients, and the feeling is that what we’re doing is beneficial, even if there isn’t science. We need to come up with a system so that oncologists are more comfortable delivering care appropriately,” said Dr Breidbart. “We need to have difficult conversations with the patients before they go on first-line therapy, not after they fail it, so the care can continue.” Some large employers are initiating discussions about living wills and endof- life care with wellness programs and their members, said Dr Lopes. She added that physicians’ offices or medical homes rarely have the infrastructure in place to assist members and their families in this way.

Variability in Care
Pharmacy is attempting to reduce variation in care and divergence from pathways by becoming more involved with the management of oral oncology products and moving slowly into the infused products, Mr Calla pointed out. “We’re working with the health plans and doctors to ensure that doctors are adhering to the pathway at least initially, or if they are deviating from them, [to see if] there is a documented reason,” he said.

Perhaps rewarding physicians for practicing better medicine could im - prove care by reducing variation, but how best to accomplish this goal is open to debate.

“In many instances we don’t pay certain doctors enough to deliver the kind of care we want for our members and our families,” Dr Breidbart acknowledged. “In addition, it is best to pay in a way that aligns incentives. If we pay somebody for piecework, we’re going to get a whole lot of pieces,” he said.

“If we want the doctor to spend his or her time thinking, then we should pay the doctor for thinking. Sometimes paying the doctor for thinking makes it look like we’re paying the doctor to reduce care, so we have to be careful about the way we pay,” observed Dr Breidbart.

“In cancer care, variability is the norm. At the heart is how we reduce variability,” Dr Chitre explained. “How do we stop paying for things that don’t have value, or pay for things that have value, like paying for preventing readmissions? We must change the landscape as far as how we define outcomes and aligning incentives.”

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