CareFirst Oncology Management Program Aims to Manage the “Entire Oncology Patient”

June 2012, Vol 3, No 4

Houston, TX—The Oncology Management Program at CareFirst Blue Cross Blue Shield (BCBS) continues to evolve, producing nearly 10% in cost-savings over prepathways practice, and ensuring that patients get more appropriate care, said Winston Wong, PharmD, Associate Vice President of Pharmacy Management at CareFirst BCBS, who described the program at the Second Annual Conference of the Association for Value-Based Cancer Care.

“With over 400 novel drugs in the oncology pipeline, most of which are expensive biologic/biotech formulations, the ability for payers to control oncology costs will become even more difficult,” Dr Wong said.

CareFirst Oncology Management Program

CareFirst developed its Oncology Management Program in 2008. The program is managed by P4 Healthcare and is based on compliance with pathways for breast, lung, colon, and prostate cancers; hematologic malignancies; and supportive care. Com - pliant parties receive the standard fee schedule plus a differential; noncompliant parties receive only the standard fee schedule.

“We call it a ‘true P4’ program—pay for performance or pay for quality—because there is no detriment to a physician or practice that does not participate; they simply get reimbursed at the standard fee,” Dr Wong said. “If practices participate (80% pathway compliance is expected), they are reimbursed at a higher rate. So in essence, we are taking some of the savings we projected and giving them back to the physician practices.”

Brand Utilization.
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Over the first 2 years, net savings reached 9%, primarily through the reduced utilization of branded antineoplastics in breast, lung, and colon cancers (Figure). Two years of savings totaled more than $17 million, of which more than $12 million was in drug costs, nearly $4 million was in service costs and more than $1 million was in supportive care costs.

The pathways program encourages the use of generics via a modified generic fee schedule that inflates reimbursement to average sales price plus 300%, Dr Wong said. “What we are trying to do is encourage the use of generics, trying to make up for some of the margin lost on the brand, but still have an overall lower cost than for the branded product.”

The company figured that $2.3 million was saved by eliminating prepathways regimens. Of interest, 60% of the savings in antineoplastic spend are minimizing the use of bevacizumab- containing combinations.

The pathways program also has reduced variability by 10%, and this accounts for approximately 4% of the total cost-savings. In addition, there has been an absolute 3% reduction in the percentage of patients who visit the emergency department during a given line of therapy.

Second-Generation Program CareFirst began taking the next step in April 2011, implementing a comprehensive second-generation program that addresses the “entire oncology patient,” Dr Wong said, in the following manner:

  • Including treatment pathways, representing a balance of best treatment practices and cost-efficiency
  • Incorporating the management of nonmedication services, such as laboratory studies, radiology, and radiation oncology
  • Incorporating end-of-life and hospice services
  • Removing the potential influence of drug reimbursement by reimbursing for professional services only: treating physicians are reimbursed for cognitive services and a flat infusion fee is given for infusions.

“We are taking the margin out of the drug and putting the margins into an inflated E/M [evaluation and management] code,” Dr Wong said. This minimizes the incentive to give chemotherapy because of drug margins. “And we are encouraging the physician to talk to the patient,” he added.

“If we are paying the physician’s practice through the E/M codes, there is the possibility that they may use an oral drug. We are allowing the physician to truly make a clear and clean decision,” he emphasized.

In general, as the “savings pool distribution” shifts from the current model to the proposed model, drug margins will be nominal (enough to cover processing, handling, and storage of drugs) and the bulk of the reimbursement will be for professional services.

The second-generation Oncology Management Program will also include some of the features of their primary-care patient-centered medical home, such as ensuring patient followup within 24 to 48 hours of chemotherapy infusion and taking measures to keep patients out of the hospital. Onsite audits of charts will also occur, to establish that recommendations such as hospice referrals are being followed. Practices will receive feedback, with physicians compared with their practices and practices compared with the program. In addition, quality measures, such as the use of hospice care and administration of chemotherapy within 2 weeks of mortality, will be reviewed.

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