Health Payors, Health Care professionals working together on Cancer

Historically, the public has reacted to a cancer diagnosis with special alarm: “Despite significant improvements in treating many types of cancer, the diagnosis is often received on the part of a patient and his or her family with a sense of doom and panic,” Managed Healthcare Executive recently noted.

Their health insurers, in turn, have approached their role in cancer treatment with particular wariness. “Traditionally, payors and providers have been more cautious to manage the costs of cancer care compared to other conditions and specialties,” Becker’s Hospital Review wrote.

One reason for this attitude is that oncology is a field marked by specialization, complexity and rapid evolution. “The second factor is the sensitivity around the emotionally charged disease. When trying to [rein] in costs, health plans and providers have generally followed an old saying: Kids and cancer are off limits.” That’s starting to change.

Given that 1.6 million Americans will be diagnosed with cancer this year – and in just five years, the cost of treating this disease will reach $158 billion annually – “payors and providers seem genuinely interested in meeting each other halfway when it comes to cancer care and costs,” according to Becker’s.  

As an executive at one cancer facility said, “[W]e've … reached out to our biggest payors and said we want to participate in this together. We need to be partners.”

Health insurers have participated in a number of initiatives in recent years to study how they might take on different roles in cancer care. Let’s take a look at a few of them.

The UnitedHealthcare pilot

UnitedHealthcare worked with five medical oncology groups to measure the effects of an episode payment model for 810 patients with breast, colon or lung cancer. According to the company, oncologists received the same fee regardless of the drugs they provided. “Patient visits were reimbursed as usual using the fee-for-service contract rates, and chemotherapy medications were reimbursed based on the average sales price … This approach was designed to reward oncologists at current levels for patient care while simultaneously severing the link between drug selection and income.”

The results were published in the Journal of Oncology Practice. The predicted fee-for-service cost was more than $94 million, but the actual cost for this group was roughly $65 million. However, the chemotherapy drug cost was just under $21 million, substantially higher than the predicted $7.5 million.

“Problem solving involved the participation of physicians, the medical group business executive, nursing staff, and payer staff. We believe that collaboration was an essential element to obtaining the result,” the authors concluded. “The episode payment project yielded significant savings for the treatment of patients with cancer without any measurable effect on quality outcomes or toxicity. This study challenges the assumption that any reduction of resources results in worse outcomes for cancer.”

In late 2014, the company announced a project in which it will pay MD Anderson Cancer Center a set annual amount to cover the cancer care for an anticipated 150 patients with head and neck cancer. “Others are trying to develop such payment bundles in cancer care,” a Harvard expert told the Wall Street Journal, and the new project “will be very closely watched.”

The Anthem study  

Anthem began a program in July 2014 that pays participating oncologists $350 per month per patient for planning treatment and coordinating care when they “select a treatment regime that is "on pathway" or matches Anthem's treatment guidelines,” according to FierceHealthPayer.

The insurer presented preliminary results in a poster at the ASCO annual meeting earlier this summer. It discussed 5,538 patients with breast, colorectal and non-small cell lung cancer who were registered at 616 practices. Out of these patients, 63 percent of breast and lung cancer patients received an approved regimen, as did 72 percent of colon cancer patients.

An Anthem vice president told the Wall Street Journal that “before the program, the baseline rate for use of its recommended treatment pathways was around 40 percent to 50 percent” and that the percentage of registered patients receiving the recommended regimens was “higher than our expectations.”

Matching Cancer Cases with Specialists

At Advanced Medical Reviews (AMR), an independent review organization (IRO), the value of matching cancer cases with specialists and expert reviewers does not go unnoticed. As Dr. Louisine Alpern, vice president of clinical services, notes, “We have a variety of oncologists on our review panel at AMR who cover everything from radiology to hematology and who can provide an expert opinion to improve the overall healthcare of cancer patients.”