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How Payers Can Improve Coordination With Oncologists


Payers struggle to determine the appropriate criteria for covering innovative treatments and providers want to increase patient access. Patients’ lives can hang in the balance.



CAR T-cell therapy and other immunotherapies may cure patients who have endured multiple rounds of treatment. Without access to these innovative therapies, many patients may have no other options.

But these therapies are expensive. At $475,000, Novartis’ Kymriah (tisagenlecleucel) is approved by FDA for patients up to 25 years of age with B-cell precursor acute lymphoblastic leukemia that’s refractory or in second or later relapse. Gilead’s Yescarta (axicabtagene ciloleucel), at $373,000, is approved for adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy. And neither price tag includes the care surrounding these treatments, which can reach $1,000,000.

Payers struggle to determine the appropriate criteria for covering these innovative treatments and providers want to increase patient access. Patients’ lives can hang in the balance.

Stacie Dusetzina, PhD, professor of health policy and cancer research at Vanderbilt University Medical Center, says patients often wait three months for a payer to approve CAR T therapy.

Thus, here are three ways to improve coordination between payers and oncologists:

Coverage for remote care management

Chemotherapy- and immunotherapy-related side effects can send patients to the emergency room-that is, if oncology practices don’t proactively manage patients and provide timely triage.

But much of this care is done on a remote basis-and is often not billable, laments Ann Marie Edwards, a Philadelphia executive with experience running an oncology practice. This is challenging for practices, which must invest in staff to provide these services.

More private payers should take a page from CMS’ book, she says. CMS’ oncology care model (OCM) provides practices $160 per month for each beneficiary who receives what the federal agency calls enhanced oncology services, which includes care management.

Related: Is Precision Medicine Worth the Hype? Oncologists Weigh In

Greater transparency

Edwards also wants payers to share more claims data with practices on patients’ utilization of resources.

More payers should emulate CMS, she says. Through OCM, the agency gives participating oncologists claims data on patients attributed to their practices. This includes claims for oncologists’ services, in addition to all other providers, including pharmacy and hospitals (such as radiology).

“By having such transparency as to where costs are highest for these oncology patients, or patients who may be high utilizers of pharmacy or [emergency room] visits, the oncologist can provide navigation, education, or care management to direct care more appropriately where possible,” she says.

Flexibility with treatment paths

Ann McGreal, RN, oncology nurse clinician at Park Ridge, Illinois-based Advocate Lutheran General Hospital, expresses frustration with some payers’ reluctance to approve medications outside National Comprehensive Cancer Network (NCCN) guidelines.

For example, an oncologist at her practice wants to treat a patient with Halaven (eribulin mesylate) for breast cancer.

Because the practice couldn’t secure approval from CMS, the patient is instead being treated with Doxil (doxorubicin), which “we know works slower and is likely to cause her more toxicities,” says McGreal.

The patient has already received two rounds of intravenous chemotherapy, she adds.

This is just one situation where her practice wants more flexibility with the appropriate treatment for patients. “We have the same difficulty with many standard insurers and many other medications.”

Her recommendation? Create a direct line of communication between her practice’s oncologists and an oncology-trained physician at the payer.

“We are frequently speaking to someone who doesn’t understand the treatment or the diseases,” she says. “I have often been told that the person making the final decision has no oncology experience.”

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