Aetna manages cancer care

July 1, 2011

Cancer is a complex, costly condition. However, emerging trends in the system at large are opening up opportunities for managed care.

Cancer is a complex, costly condition to treat. However, emerging trends in the healthcare system at large are opening up opportunities for managed care to drive savings.

Aetna was able to realize 35% lower average costs over 12 months for patients with non-small cell lung cancer when oncologists applied evidence-based care. In the study, which was released last year, those patients treated by physicians using an evidenced-based protocol that was provided by Aetna and US Oncology incurred average costs of $18,042 versus $27,737 for those who were not. The difference was attributed to lower costs for chemotherapy medications.

As is often the case, more care or more costly care did not provide improvement. Outcomes for patients in the evidence-based group were similar to the control group.

"There's tremendous variability with regard to the management of like cases, which is particularly troubling in the context of cancers where there are incontrovertible standards about what is best based on evidence-based trials," Dr. Reisman says. "To the extent that that variability exists, and to the extent that we can work with doctors to establish what guidelines ought to exist and provide incentives for doctors-and arguably, patients-to adhere to those guidelines, we think we can eliminate some of the variability."

And adherence to treatment standards can result in lower costs, he says. In Aetna's case, it was able to realize 35% lower costs for lung cancer treatment by providing physicians best-practice protocols as well as bonus payments for following them.

Aetna spends $1.2 billion a year on cancer care. The health plan works with oncologists to apply evidence-based guidelines from the National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of leading cancer centers, and the American Society of Clinical Oncology. Guidelines are incorporated into its care decisions as well as reimbursement methodology.

Immediate cost concerns

The National Institutes of Health estimates that there were more than 1.5 million new cancer diagnoses in 2010, and the overall cost of cancer reached $263 billion.

Clearly, cost containment is a growing concern. For example, more than 900 drugs in today's pipeline target cancer, and many of them are costly specialty drugs.

While the backlash against managed care in the 1990s had insurers backpedaling on cancer coverage limits, preauthorizations and other utilization policies, today's atmosphere is changing. Greater acknowledgement of spiraling costs and an aging population has the attention of the public as well as policymakers.

According to Dr. Reisman, the cooperative model of care that patients and providers want also offers an opportunity for payers to drive the kind of care quality that saves money.

"What's changed particularly as it relates our role, is that there is a much more collaborative relationship between the doctor and the patient with regard to how care is rendered," he says. "Contrast that to the model where basically a patient goes to a qualified doctor who would diagnose, stage and treat in a way that he or she deemed appropriate, and then we would basically pay for those services."

As a follow-up to the 2010 lung-cancer study, Aetna introduced a voluntary comprehensive cancer management program for providers in select markets. US Oncology and its Innovent Oncology subsidiary are providing technology resources, the clinical program and evidence-based guidelines for 14 of the most commonly diagnosed cancers.

US Oncology-affiliated physicians who participate in Aetna's network have an opportunity to apply the clinical protocols for Aetna members' cancer care. Health information technology is layered over the clinical elements to give physicians electronic access to these protocols and other decision-support resources at the point of care.

Program highlights include: best-practice chemotherapeutic and pharmacy usage; evidence-based care that can be measured against national benchmarks; and integrated care management.

"We would like to see providers working closely with patients to improve health outcomes and lower medical costs," Dr. Reisman says. "We can advance outcome-oriented practices by providing both health information technology and care management support."

In February, Aetna also began a collaborative cancer care program with Cardinal Health's P4, a healthcare management services company. Regional committees of oncologists in the Aetna network are identifying evidence-based treatment regimens for breast, lung and colon cancers and applying the pathways into daily practice. Technology tools provide decision support, track outcomes and analyze cost data.

The program also allows oncologists to share in the savings.

"What we see as a significant role for us is using a combination of information technology-which has been a couple-billion-dollar investment-coupled with incentives for providers in terms of collaborating on the development of these guidelines and payment incentives," Dr. Reisman says. "The confluence of those events-emerging evidence, recognition of variability, incentives, technology, all of those things combined-represent what we consider to be a significant opportunity to promote quality and lower costs."

The regional physician committees are already established in Maryland and Florida, with Georgia, Virginia and Washington, D.C., in the early stages of implementation.

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