A Payer-Provider Collaboration to Add Value to Oncology Care

Aetna and the University of Chicago Medicine kicked off a value-based oncology medical home model in July this year in an effort to transition from fee-for-service to value-based care.

What happens when a leading payer organization teams up with one of the best hospitals in the country to deliver cancer care? Aetna and the University of Chicago Medicine kicked off a value-based oncology medical home model at the hospital in July this year, which will initially include Aetna members receiving treatment for breast, lung, and colon cancer with plans to expand to other tumor types.

A big stumbling block with keeping care costs down are follow-up events where the patient may seek care at another site and not where he or she received primary care for cancer. This creates a disconnect in data capture. “Now, with data from Aetna, we will have complete information on these patients,” said Walter Stadler, MD, chief of the section of hematology/oncology at University of Chicago.

Clinical Pathways: a Tool to Streamline Costs

Over the past few years, several payer-developed models have been evaluated for their potential to regulate cancer care costs. With the advent of novel immuno-oncology molecules like the PD-1, PD-L1, and CTLA-4 inhibitors, physicians are including the word “cure” on data slides—but these biologicals do not come cheap. Payer-developed clinical pathways seem all the more relevant when we look at the $100,000 price tags on these new drugs, with the costs adding up with combination therapies, adjuvant treatments, supportive care, and of course costs associated with diagnostic tests, imaging, and so on.

While there has been resistance from providers who argue that they are the best judges of what treatment works best for a patient, Michael Kolodziej, MD, national medical director for oncology solutions at Aetna says, “We believe compliance with evidence-based pathways is a critical component of success. In our relationships with community oncologists, we require use of a pathways tool, though we do not dictate a specific tool.” In a recent webinar hosted by AIS Health on oncology management, Dr Kolodziej presented data that showed adherence to evidence-based guidelines significantly reduced care costs without impacting treatment efficiency and also that generally, physicians do follow pathways— be they practice generated, payer generated, hospital generated, or maybe by a third party.

A pilot study conducted by Aetna oncology with 156 physicians who were provided with clinical decision support tools resulted in a net savings of nearly $400,000 in reduced visits to the emergency department, in-patient stays, and drug costs; treatment variability reduced by 28% and generic use increased by 11%. All along, the quality of care was maintained, Kolodziej shared during his presentation.

But this might be a slow process of change and collaborations—such as the recent one with the University of Chicago and earlier with Moffitt Cancer Center in Florida—can help. “Since most of our practices have not used pathways in a rigorous fashion, we anticipate there will be a learning curve,” said Koldziej.

An accreditation program, developed by the American College of Surgery Commission on Cancer, is also in the works for these oncology medical homes.