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Evidence-Based Oncology December 2015
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Managing Costs and Enhancing the Value of Oncology Care
Surya Singh, MD; Christine Sawicki, RPh, MBA; Ken Vander Pyl; Alan Lotvin, MD
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Managing Costs and Enhancing the Value of Oncology Care

Surya Singh, MD; Christine Sawicki, RPh, MBA; Ken Vander Pyl; Alan Lotvin, MD
Management of high and rising costs in oncology requires a multifaceted approach using both innovative strategies and pragmatic tools. In this article, we discuss several factors that influence the costs of oncology care.
MANAGEMENT APPROACHES
 
Against this evolving array of cost driv­ers, managed care organizations and pharmacy benefit managers have cre­ated a portfolio approach to oncology management in which 1 or more of several approaches are applied in an ef­fort to increase the value of cancer care delivered to patients. These approaches include the following and have been listed in FIGURE 4:
 
1.      Prior authorizations are increas­ingly applied to chemotherapeutic medications in an effort to reduce off-label prescribing of these drugs and utilization that is not support­ed by the NCCN guidelines. During the prior authorization process, in addition to addressing the indica­tion for use of a specific agent, the duration of therapy is also typically addressed, rather than granting long or open-ended authorization intervals.14
2.      Claims editing is another approach that is used to ensure payment for on-label dosing and indications. While not uniformly adopted, to be most effectively implemented, edits must be deployed against all oncology drugs whether they are infused, injected, or orally admin­istered, or adjudicated under the pharmacy or medical benefit.
3.      Plan design is playing an increas­ingly significant role in oncology management. Recent years have seen the introduction of some fre­quently prescribed generic drugs in oncology (e.g., capecitabine in co­lon and breast cancers), and there is accelerating activity in this area. Coupled with the first biosimilar Zarxio (filgrastim)15 in 2015, there is likely to be an increased need for multi-tiered plan design and po­tential formulary exclusions (with appropriate medical exceptions) in oncology.
4.      Care management of oncology pa­tients can be quite complex, but es­sential to achieve high-quality care. During this time, patients rely heav­ily on their health care providers. Further, disease progression and response to treatment vary, which leads to highly individualized pa­tient needs. These complexities ne­cessitate a sophisticated nurse-led care management approach, which provides support to patients in sev­eral areas, including, but not limited to: assessment and management of side effects, compliance with nutri­tional plan and recommendations, interventions for reducing infection risk, and facilitation of end-of-life care discussions.
5.      Adherence to oral and infused treat­ments in oncology can be optimized through proactive consultation to identify and address potential barriers to compliance and persis­tence. A comprehensive nurse-led care management approach also includes tools and resources to ad­dress root causes that may lead to non-adherence, such as unrealistic patient expectations, inadequate levels of health literacy, existence of comorbid conditions, concurrent drug therapies, and the need for as­sistance with financial concerns.
 
The treatment of cancer frequently requires medication infusion and/or in­jection by a clinician, for which a site of care must be selected. This decision is usually made based on the preference of the treating medical oncologist. For some aspects of patient care—including supportive drugs, such as antiemetics and blood cell growth factors—an alter­native site of care for drug administra­tion can be offered, such as home or am­bulatory infusion centers. These sites offer greater comfort and convenience to certain patients, while also being cost effective.
 
Personalized medicine is an evolving field in which physicians use diagnostic tests to determine which treatments will work best for each patient.16 In breast cancer, a recurrence score based on a 21-gene assay (“Oncotype DX”) has been shown to determine whether chemother­apy, in addition to hormone therapy, will be incrementally beneficial in lymph-node negative, hormone-receptor posi­tive patients. In essence, Oncotype DX allows physicians to identify those pa­tients in the relevant subpopulation who would best respond to chemotherapy (in addition to well-tolerated and relatively inexpensive hormone therapy). This may also help reduce the unnecessary cost of treating non-responders.17 Recently published results from the prospective TAILORx trial of this assay demonstrate that women with low recurrence scores (16% of the studied population) had a 98% survival with hormone therapy alone, as well as a rate of freedom from cancer re­currence of almost 99%, providing sup­port for the clinical validity of this test, and its ability to lower the cost of care when used appropriately.18
 
EMERGENCE OF VALUE-BASED CANCER CARE MODELS
 
Sustainably addressing the oncol­ogy cost drivers also requires new ap­proaches that not only incorporate tra­ditional management approaches, but also go beyond the existing methods. Some degree of redesign in how cancer care is delivered is necessary in order to enable the iterative enhancement and measurement of value through new ap­proaches. If providers are expected to meaningfully alter their practice pat­terns, they must be rewarded for higher quality and/or more efficient care. In­stead of simply paying more for greater volume for individual point of care ac­tivities, the focus should be more holis­tic, at the patient or episode level. While experimentation with 2 such models— cancer care pathways and bundled pay­ments for cancer episodes of care—have been most popular, other models and tools aimed at enhancing the value of oncology care are emerging.
 
Cancer care pathways aim to reward providers for performance, offering greater reimbursement for following es­tablished, evidence-based care recom­mendations. Some payers have seen measurable success with pathways while others have experienced barri­ers in pathways adoption. Aetna and The US Oncology Network’s cancer-care management program is one such ex­ample of a pathways program that re­ported a modest reduction in hospital­izations and treatment costs for lung, breast, and colorectal cancers, but the firm evidence for substantial impact on costs attributable to oncology pathway programs has been minimal.19
 
Payers continue to experiment with bundled payments for all care delivered to patients. Such an approach offers a single payment for the full episode of care, creating incentives to reduce to­tal health care costs. UnitedHealthcare recently reported the results of such a study in 5 medical groups, and their in­tervention also featured a stronger data feedback loop to providers to improve care management. The experiment led to substantially reduced healthcare   costs, but paradoxically led to increases in prescription drug spending.20
 


 
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