Traditionally, management of oncology has been split among various areas of the health plan. This may include a pharmacy department that performs drug prior authorization, medical management that performs general utilization management, case managers that deal directly with some of the sickest patients, or a disease management area focused on education and coordination. Sadly, many of these areas do not coordinate activities and the member is caught trying to navigate a complex process, while dealing with a devastating diagnosis and treatment.
Over the years, there has been recognition that screening and earlier diagnosis drives better treatment options and earlier access to clinical drug trials, along with an opportunity for patients to manage treatment decisions up to and including end-of-life choices on their own terms with quality care and family support.
A critical component of oncology management is drug therapy. This area of research and development continues to grow, and the constant deluge of new information and available treatment options can be overwhelming. Coupled with confusing drug benefit designs, prior authorization, deductibles, copay assistance programs, rebates, 340B, clinical trials, site of care, medication distribution and clinical guidelines, there seem to be never-ending challenges for providers and members to navigate.
Here's where a comprehensive oncology management program that supports the clinicians, patients, and caregivers from diagnosis through end-of-life comes in. Coordinated benefits, drug regimen review, care navigation and clinical decision support can lead to better patient experience, improved quality, and lower costs.
A new perspective
Medical and pharmacy directors should consider a comprehensive oncology management program that is coordinated across benefits and health plan functions; and addresses all stakeholders and activities from initial diagnosis through end of life. A comprehensive program considers insourcing vs. outsourcing core competencies, clinical guidelines, coordinated utilization management review including full drug regimen review, network and benefit channel optimization, and other best practices.
The approach starts with an understanding of the member experience and a clear picture of the total cost of care. Then, a deep dive into various areas such as inpatient, outpatient, drugs, radiology, care management and other areas to fully understand the cost and quality drivers to identify areas of opportunity. Strategy development and execution requires a baseline measure of costs and quality, and a vision for a desired state. When the data tells the story, there are often “aha” moments that would otherwise be missed when decisions are made in silos.
Many health plans address individual components of costs in silos such as drug prior authorization, site of care programs or vendor contracting for radiation management. A better approach is to bring the internal leaders together who hold accountability for all the oncology care and cost components in order to align on goals and strategic direction, considering how the decisions impact member and provider experiences. Following this, they can prioritize, coordinate, and plan the areas to be addressed, ensuring that all stakeholder input is considered.
A blanket of benefits
The benefits of designing and building a comprehensive oncology management program are threefold: improved member experience; lower costs and improved quality; and better collaboration between various departments of the health plan.
Let’s look at the recent pandemic as an example. With lockdowns and delays in place during the peak of COVID-19 in 2020, routine screenings were put on the back burner, which meant delayed diagnosis and treatment. This backlog means the disease is diagnosed at a later point of progression, driving the need for more aggressive treatment and limiting treatment choices. The trickledown effect is an increase in the demand for care navigation and coordination, and overall increased costs to the plan. The pressure on the health system is accelerating innovation with how and where care is delivered. Health plans play an important part in making this process smoother, which can be achieved through an organized, coordinated, comprehensive approach.
A step forward
The complexities of cancer are familiar to most. As opposed to one-dimensional diseases that have a more straightforward treatment plan, cancer can be much more complex. Cancer diagnosis and treatment can vary by organ and system. Unless health plans have in-house oncology medical and pharmacy experts, staying on top of treatment guidelines, new drugs and clinical trials, the various radiation and medical oncology treatment options can be confusing, making utilization management review processes difficult and, worse, many times ineffective.
The influx of information and administration of clinical policies can be unmanageable by most health plans. One option is to consider contracting with oncology experts to manage the utilization review and provide care management and navigation support, allowing the health plans’ medical management teams to focus on their areas of competency.
At the end of the day, members’ experience and health outcomes is the most important part of our work. A strategy that brings medical and pharmacy teams together to close the gap in cost of care, quality, and member satisfaction is critical to the success of any healthcare program.
Christine Gunderson is a director and Leslie Lotano-Saba is vice president in the Pharmacy Solutions practice of AArete, a global management consulting firm.