By Jennifer Hinkel, MSc
NCCN eBulletin Editor-in-Chief
As health care costs in the United States continue to rise, managed care organizations (MCOs) are targeting areas where use of expensive interventions might be better managed, and cancer is becoming a priority area of concern. As costs of cancer interventions rise, managing access to and availability of cancer treatment presents a significant challenge to payors. NCCN discussed the current state of affairs with executives from three major managed care organizations to gain the payor's perspective on these issues and learn how patients, providers, and industry might be impacted.
Payors are adopting new methods to identify inappropriate uses of cancer drugs and biologics and readopting older ones, including precertification and use of formularies and tiering. Increasingly, MCOs are willing to base oncology coverage decisions on information tools such as compendia and or to effectively “outsource” some functions of drug coverage, precertification, and reimbursement to pharmacy benefit managers (PBMs) and specialty oncology pharmacies.
Applying cost-reduction strategies to medical oncology management, previously a near-anathema or at least a taboo, is gaining new ground in the context of rising costs and a grim economic environment. For a typical managed care organization, cancer spending is one of the top three categories for medical expenses. An attitude shift is taking place in the managed care world with regards to cancer care; medical oncology decisions are no longer fortified against scrutiny and intervention by decision-makers in the payor world. As stated by one managed care executive, “cancer is now on the table.”
Each of the three major MCOs consulted by NCCN are approaching cancer in a slightly different manner, but some commonalities exist. Physician reimbursement mechanisms, coverage of new oncology agents (especially “off-label” uses), and methods for the evaluation of appropriate and quality care seem to rank high on the list of priorities. To a lesser extent, benefit design that includes higher cost-sharing (copayments or coinsurance) for certain agents and access to oral agents only through a “specialty pharmacy” are other management tools used by many MCOs.
Managed care organizations have a growing interest in measuring the quality of care being delivered to their beneficiaries. In oncology, these efforts take a number of forms, including collaborations between payors and providers, databases that track care that is delivered and benchmark the care against existing recommendations, and tools that prospectively help the provider deliver quality care through “decision assist.”
As one example of efforts to benchmark care against existing recommendations, health research and information company Ingenix is collaborating with the National Comprehensive Cancer Network to develop a quality evaluation tool for payors that will use clinical, billing, and administrative data to benchmark against key recommendations found in the NCCN Clinical Practice Guidelines in Oncology™ for several high-incidence cancers. By collecting more in-depth data regarding a patient's disease status and looking longitudinally across different interventions, tools such as these will be able to more closely analyze how providers are treating patients in concordance with standards of care for oncology.
Despite advances in information and technology that are enabling MCOs to more closely scrutinize the delivery of cancer care, managed care executives acknowledge that a “trust gap” exists between patients and providers on one side and managed care organizations on the other. One managed care representative said that “in trust, payors are at the bottom of the totem pole” from the patient's perspective.
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