Quality program to provide value, identify clinically effective solutions
WellPoint has unveiled a quality initiative to help identify cancer treatment therapies that are clinically effective and provide greater value, underscoring that cancer care costs have been top-of-mind for plans.
“This program identifies certain cancer treatment pathways selected based upon current medical evidence, peer-reviewed published literature, consensus guidelines and WellPoint’s clinical policies,” says Lori McLaughlin, WellPoint representative. “The goal of the program is to help ensure that our members have access to quality, evidence-based affordable healthcare.”
Because cost-effective and clinically proven treatments typically mean lower drug costs or fewer hospitalizations due to toxicity, McLaughlin says that savings like this will allow WellPoint to keep premiums more affordable.
The WellPoint Cancer Care Quality Program, developed in collaboration with WellPoint subsidiary AIM Specialty Health, will allow oncologists to compare planned cancer treatment regimens with evidence-based clinical criteria and potentially receive enhanced reimbursement. To be eligible, oncologists must be in-network for the member’s health benefit plan and select a treatment regimen that is designated as a cancer treatment pathway.
“This program offers oncologists a way for their patients to receive evidence-based treatments that can potentially reduce toxicity to patients while allowing them to potentially recoup revenue they might have otherwise received from the sale of high-cost therapies,” she says. “Oncologists can choose regimens that are not designated as a cancer treatment pathway and will continue to be reimbursed for visits and cancer drugs according to the terms of the member’s health plan. However, only pathway regimens are eligible for enhanced reimbursement.”
Oncologists who choose the pathways for their patients also have many therapies to select from. McLaughin says WellPoint has identified 24 pathways for breast cancer, 16 for colorectal cancer and 22 for lung cancer.
According to WellPoint analysis, substantial variations in costs can exist for equally effective treatments. Variations in side effects and costs for adjuvant therapy for HER2-negative breast cancer with similar outcomes range from $13,000 to $32,000.
According to Jon Maesner, PharmD, Cigna’s chief pharmacy officer, Cigna has a variety of solutions in place and in development to help with the
affordability of cancer therapy.
“These solutions include assuring the appropriateness of therapy through prior authorization review services and innovations in physician drug reimbursement that favor lower cost drug selection when such is available and clinically appropriate,” he says.
Cigna has completed early pilot work related to care pathways and will continue to assess the value of this work in achieving its three-part goal of improving clinical quality, affordability and customer experience related to cancer care.
“Health plans want to limit the use of the new targeted cancer therapies because, they claim, it will control costs,” says Robert Goldberg, PhD, founder of Value of Medical Innovation. “Yet such innovative medicines reduce hospitalization and the use of other medical services. This is a principle reason cancer costs as a percent of total healthcare spending-and cost per cancer survivor-is projected to decline.”
According to Goldberg, since 2006, the number of these targeted treatments has grown from 11% to 46% of all cancer drugs, while cancer death rates have declined by 20%. The proportion of spending on inpatient cancer
admissions fell from 64% of total cancer spending in 1987 to 20% in 2012.
“The cost of these innovations as a share of what we spend on healthcare is less than 1%,” Goldberg says, citing that in 1987, spending on cancer care was 5% of total healthcare expenditures. In 2012, it was 4.2% of the $2.8 trillion expended on all healthcare in the United States. By 2020, the National Cancer Institute projects that cancer care will cost $158 billion.
“By then, cancer care’s share of medical expenditures will actually decline to 3.6%,” he says. “This has happened as the number of cancer survivors has surged, death rates have declined and quality of life has increased. New cancer therapies are responsible for most of this progress, yet plans want to pay doctors bonuses for limiting their use.”