Philadelphia, PA—Third-party oncology benefits management, tiered networks, and accountable care organizations (ACOs) are some of the trends gaining traction in the health insurance industry, according to Donald Liss, MD, Senior Medical Director, Independence Blue Cross of Philadelphia, who described cancer care from a large insurer’s perspective. Health plans, viewed as moderately simple entities, carry a 3-fold set of responsibilities, said Dr Liss. The first responsibility of a health plan is to offer a benefits plan, typically on behalf of a purchaser (eg, employer, governmental entity, labor union) that will cover medically necessary, non - experimental services. The second responsibility is to contract with a network of providers, negotiating for price, trading volume for discount, and ultimately offering availability of access to membership. The third responsibility of health plans is to adjudicate and pay claims. “The goals are to figure out whether someone is at high risk, and whether a benefit is useless or wasteful,” said Dr Liss, Senior Medical Director of Clinical Programs and Policy at Independence Blue Cross. Shifting Makeup of Benefits In benefit design, there’s a growing trend among payers toward shifting the cost burden more toward the patient by increasing the out-of-pocket costs, including premiums, copayments, deductibles, and coinsurance at point of sale. “These are blunt instruments applicable to categories of services— office visits, outpatient procedures, and diagnostic imaging—but they do not distinguish value of service,” Dr Liss said. “Those increased costs for the consumer clearly have the intended effect of reducing costs for the insurer, but whether they are differentiating highvalue services and low value is not so clear,” he said. Transparency is another challenge in benefit design. It concerns issues of where the service is being performed—“ Is it part of a physician’s office, an infusion center, or a hospital outpatient department?” Trends to Watch Among the recent trends in the industry (Table), tiered networks, regarded as high-quality networks, are gaining a foothold among providers. As recently as 2003 or 2004, nobody could show significant benefits of these trends for health outcomes, according to Dr Liss, but the ability to show significant outcomes with these strategies has improved.
Self-injectable medications are moving away from medical benefits to pharmacy and pharmacy benefits management. Of significance is the move toward more careful review of the high cost of cancer treatments. Health plans are increasingly more sensitive to issues surrounding dosage and frequency, ensuring that claims they are paying are for drugs and treatments that were actually given. A move toward oncology benefits management by third parties has arrived, based on experience in diagnostic imaging and other focused service lines, Dr Liss observes. In addition, there is an effort to collaborate with organized oncology groups. Dr Liss points to a macro industry of oncology benefit management firms that are in existence today. The ACO is yet another noteworthy trend to monitor, according to Dr Liss. “How ACOs organize themselves— and cancer care is a fascinating window to view this—is significant, because treatment of cancer is an intense expense for a small group of people,” he says. “If the population for an ACO that is both clinically and financially accountable simply has bad luck with a couple of people with very high-cost cancer therapy, they’re screwed. The whole concept of health insurance is to spread risk across huge populations. An ACO has got to be big enough to balance those risks—the law of large numbers.” Expect molecular diagnostics to present a huge opportunity and challenge in managing the expense of technology. With regard to the Patient Protection and Affordable Care Act (ACA), the elimination of lifetime limits and preexisting conditions is “a huge deal” in oncology, especially as the cost of cancer therapeutics increases, according to Dr Liss. The ACA helped with the establishment of essential benefits, which are loosely recognized as services that will be covered in the insurance plan, and with the determination of how each plan will distribute those benefits to individual cases. One final trend to watch in the financing of healthcare involves comparative effectiveness research, which is an investment in the analysis of which therapies work.
