WellPoint’s Perspective on Value-Based Cancer Care for Today and Tomorrow

May 2013, Vol 4, No 4

Hollywood, FL—“The overarching issue that brings us to the AVBCC Annual Conference is that rising healthcare costs are unsustainable,” said Jennifer Malin, MD, PhD, Medical Director of Oncology at WellPoint, Inc, who spoke at the Third Annual Conference of the Association for Value-Based Cancer Care from the perspective of managed markets.

“In 5 years, premiums and out-of-pocket costs for a family are projected to equal half the median household income,” she noted. “Our challenge is to come to terms with this and continue to innovate in ways that ensure patients have high-quality care.”

A System Out of Alignment
New technologies, such as intensity-modulated radiation therapy for prostate cancer, are rapidly adopted, and although they are expensive, their benefit over conventional therapies is often unproven. Ironically, lower-cost therapies that produce equal or better outcomes are adopted more slowly.

In a recent study of radiotherapy for breast cancer, 62% of the patients preferred hypofractionated whole-breast irradiation, which requires fewer treatments than other modalities, but 56% of the radiation oncologists surveyed admitted to never using this approach (Hoopes DJ, et al. Int J Radiat Oncol Biol Phys. 2012;82:674-681). “This is not patient-centered care,” Dr Malin maintained.

Figure
Figure: Technology and Drugs Account for Most of the Cost in Cancer Care.
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Based on WellPoint data, although money is freely spent on technology and drugs in cancer care, with the majority going to chemotherapy (25%)and radiation oncology (15%), only 3% of healthcare dollars are spent on physician visits (Figure). “This represents a system that is out of alignment,” she commented. Margins on chemotherapy largely support the average oncology practices, but patient-centered care should be incentivized through direct payments, according to Dr Malin.

Table 1
Table 1: Variation in Outcomes Across First-Line Regimens for NSCLC.
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Multiple regimens are approved for most tumor types, and although their toxicities may vary, the differences in outcomes with these regimens are often clinically insignificant. A poignant example comes from a comparison of 6 regimens for the treatment of non–small-cell lung cancer (Table 1). The median overall survival ranged from approximately 10 months with the oldest regimens to 13 months with the newer ones. Although patients “probably would not split hairs over this” survival difference, Dr Malin suggested, toxicity might be more important to many patients. The rates of serious adverse events also had significant differences per regimen, ranging from 18% to more than 44% and deaths while receiving treatment ranged from 0.5% to 7%.

Table 2
Table 2: Little Variation in Outcomes, but Marked Variation in Cost.
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The cost differential was also significant. “When you omit the oldest regimen, with the lowest survival, there is over a 7-fold variation in cost, for what I would argue are slight differences in outcomes. Where is the value here?” Dr Malin questioned (Table 2).

Improving Value in the Near- and Long-Term
To help deal with big differences in costs relative to small differences in outcomes, WellPoint is implementing a new evidence-based decision support tool aimed at streamlining approval for episodes of care. It is a “road map” that supports value-based cancer care—ie, care that is appropriate and consistent with patient preferences—and discourages the use of regimens that are more expensive but offer no additional value.

To improve value in the near-term, WellPoint supports innovation in community practices by increasing chemotherapy administration fees and instituting tiered reimbursement for chemotherapy, and by instituting preauthorization of episode of care and reimbursement that will be tied to the overall adherence to pathways.

The increasing focus on a medical home is a long-term way for improving value, with an emphasis on treatment planning and care coordination, payment linked to performance based on pathways, disease management, and early palliative care.

The delivery of such patient-centered care will require practice re-engineering, Dr Malin added, which includes:

  • Information technology infrastructure and decision support
  • Protocols for nurse-led symptom management
  • Tools to guide patient-centered decision-making, assessment of symptoms, and need for palliative care
  • Change in culture regarding palliative care
  • Quality and outcome measurements
  • Collaborative approach to quality improvement.

“The key is ongoing innovation for practices to make these kinds of changes, and the challenge is to make this scalable,” Dr Malin pointed out. Although various models have the attention of practice leaders, knowledge is still scarce about implementing them in practice.

Innovation to Reduce Variation in Cost
As an example of innovation, Dr Malin described a program in which a plan member is informed about less-expensive alternatives. For example, during preauthorization for an imaging test, the patient is informed if a comparable facility offers the test at less cost, which may mean lower out-of-pocket costs for that patient. If the patient elects to have imaging done at the lower-cost facility, he or she will be assisted in making a new appointment.

New tools will help patients understand relative quality and cost, and this should enhance patient engagement in value. “The average cancer patient spends about $2500 in the first year in out-of-pocket costs, so he or she has skin in the game,” Dr Malin noted.

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