What Are Some Health Plan Best Practices Surrounding Oncology Therapy Coverage?


In this AMCP Market Insights session, panelists discussed best practices and challenges when it comes to prescribing antibody drug conjugates, from the payer, provider, and patient perspectives, based on survey findings.

In the AMCP Market Insights session, “Targeted Therapies to Deliver Improved Patient Outcomes in Oncology,” experts discussed key insights into antibody drug conjugates (ADCs), including best practices for evidence evaluation and safe use of ADCs, and strategies to improve the transparency of ADC coverage policies and help managed care professionals guide treatment sequencing.

The panel was led by Dana McCormick, RPh, FMACP, director of pharmacy at Blue Cross Blue Shield of Texas, and included:

  • Laura Bobolts, PharmD, BCOP, senior vice president of clinical strategy and growth at OncoHealth
  • Ryan Haumschild, PharmD, MS, MBA, director of pharmacy services at Emory Healthcare and Winship Cancer Institute
  • Bhavesh Shah, RPh, BCOP, chief pharmacy officer for hematology and oncology pharmacy at Boston Medical Center

Survey Results on Health Plan Best Practices

To get a better understanding of best practices to improve patient outcomes in oncology in health plans, AMCP first conducted 8 in-depth interviews with experts to gather a list of their best practices, and used these results to create a new set of questions. These were then used to survey 59 managed care and oncology professionals, leading up to a workshop to discuss how to apply these health plan best practices that were identified.

The survey included professionals—71% pharmacists, 23% medical doctors, 3% registered nurses or nurse practitioners, and 3% other—who worked for health plan organizations, hospitals or health care delivery systems, pharmacy benefit managers (PBMs), or other (accountable care organization, specialty pharmacy, consultant).

In the end, 13 best practices were identified and discussed, which fell under 3 main buckets:

  1. Careful evaluation of literature, practice guidelines, and emerging evidence on a targeted therapy, and creation of coverage policies and programs around the therapy
  2. Collaboration among health care professionals to support appropriate prescribing
  3. General patient support by health care professionals through their entire patient journey

To kick off the panel discussion, McCormick asked for each panelists’ thoughts on best practices for coverage criteria development, and on the sources of evidence payers say they're using when evaluating targeted therapies.

“Pre-approval information exchange data is very important because we need to understand the value of the drug prior to its launch or FDA approval as much as possible,” Bobolts answered first, saying that it’s important to know how to position the therapy and how it compares with others in the same space. “Oncology is complex; it's not easy.”

Building onto her last statement, Bobolts added that it’s important to really look deep into the clinical trial data of a targeted therapy when determining coverage criteria—not just the efficacy data, but also the design, inclusion and exclusion criteria, and other factors—as well as the resources on that therapy in general.

“Once you meet the criteria, next week it’s outdated,” she said, as the audience laughed and nodded their heads. “Welcome to oncology, people!”

All of these factors together, the panelists said, helps give guidance to the payer side, which can improve patient access to newer and better targeted therapies. Shah also stressed that patients should not be left out from accessing these treatments just because they did not meet the inclusion criteria for a certain study on the drug.

Focusing on Proactively Determining ADC Value

A more specific recommended practice that came out of the survey was the use of visual data dashboards, although less than half of the survey respondents said they actively use them in their evaluation process of ADCs. Visual data dashboards can give insight to several components of a therapy, which respondents ranked in order of value: clinical benefits, cost effectiveness, budget impact, place in therapy, contextual factors, nonclinical benefits, and societal values.

According to Haumschild, visualization is essential to help evaluate medication therapies, and these dashboards can help find the value in these therapies earlier on and help better understand the exact barriers between patients and the health care they need. While it may be a more expensive recommendation, he said, this is an emerging area that can help drive value.

Proactively determining not just the overall value, but how a treatment could directly affect a patient’s health, was also mentioned. The panelists agreed that providers should have appropriately recommended qualification and site-of-care restrictions to ensure patient safety. With ADCs having a high potential of side effects, the more providers can monitor these before they happen, the more patients can continue the therapy without actually experiencing these negative effects. Another similar recommendation was to proactively provide coverage, guidance, and decision support tools for ADCs to prevent toxicity and adverse events (AEs)

When asked about decision support tools, 73% of the survey respondents said they use oncology care pathways, protocols, order sets, or other tools to help make decisions on prescribing ADCs. Of these respondents, 60% include dose modification information to help manage ADC AEs, 60% provide preferred treatment sequencing by diagnosis or cancer stage,and 53% provide prescribing information on ADC prescription or supportive medication use.

Using decision support tools was a no-brainer for the panelists.

According to Bobolts, it’s important to look at the entire regimen because the main treatment—in this case, ADCs—may have minor side effects that are manageable by other prescriptions, like eye drops, anti-nausea pills, and cough drops. She also emphasized the importance of telemedicine and digital health management in this area.

For example, if a patient gets a minor rash caused by their cancer treatment that only requires a mild steroid cream to manage, they shouldn’t have to run to the emergency department or urgent care, which takes time out of their day and money out of their pocket. If a symptom like this can be easily assessed over a phone or video call from the comfort of the patient’s home, and the provider can prescribe a treatment for it as well, it makes the patient’s life just a little bit easier and encourages the patient from abandoning their cancer treatment.

A Look at ACD Costs

Another recommendation was to build preferred pathways and treatment sequencing using major compendia and data on clinical efficacy, AEs, and costs.

According to the survey respondents, the top 5 most important resources for treatment sequencing are, in order:

  1. clinical efficacy data
  2. approved indication(s) in label
  3. comparative efficacy data
  4. NCCN or other consensus guidelines
  5. expert opinion

Haumschild chimed in that electronic health records (EHRs) also have valuable data that can help guide any necessary dose adjustments and, again, keep patients on their treatment longer and improve their outcomes.

“Some of the health plans that really resonate with this are the ones that can call on the medical benefit spin and align them with the pharmacy benefit spin and then you're seeing more of that total picture across the continuum of care,” Haumschild said. “The more you can leverage the EHR to make decision making—usually driven through pharmacy—straightforward for the provider leading them to the right path, I think creates better compliance, dose adjustments, supportive care medications, and ultimately prescribing habits.”

The survey showed that many challenges with ADCs were related to costs, with various options to address these barriers. According to a Reuters article Bobolts cited, the average annual cost of a new cancer drug launched in 2021 cost $238,175.

“It’s not sustainable for anyone,” she emphasized, noting that drug acquisition costs are only a “piece of the pie” and that the total cost of care needs to be taken into account, with survey respondents saying costs to all involved stakeholders create major challenges with ADCs.

Shah also noted that Medicare is the largest patient population impacted by costs.

In terms of solutions to address this major barrier of costs, the top option in the survey was to maximize patient assistance programs, which Shah said Boston Medical Center has done through internal support programs, adding that there are many programs out there that are both drug– and not drug-related. However, despite being the top solution, these programs are not being access as much as they should be.

The Health Equity Lens

To close out the discussion, each panelist gave a quick insight into how all of this related to healthy equity in cancer care.

As mentioned throughout the panel, Haumschild feels strongly about really looking at each patient and patient population to better understand who the most vulnerable populations are. He also emphasized the need for patient education, so they know what to voice during the time that they are meeting with their health care provider.

Shah added noted that it’s not just about what goes on during the patient visit either, saying other barriers to transportation, food, and other social determinants of health in general greatly impact patient outcomes.

“I think we forget how nonmedical interventions actually impact the medical outcomes of patients more than the medical therapies they’re getting sometimes,” Shah said.

Bobolts added that one simple solution to help bridge health care inequities is clear: make sure patients are on guideline concordant care. In one study, patients with cancer who were not on guideline concordant care actually had a 33% increased risk of disease specific death.

“We can do better for our patients and bridge this gap in health inequity by so simple as making sure they are on the appropriate care from the get-go,” she said.

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