Stemming the cost of cancer treatment tops the focus list of every payer. Employers too are looking for solutions – last year cancer overtook musculoskeletal conditions as the top driver of large companies’ health care costs. This oncologist says there are things you can be doing that make a big difference in driving down cost and improving quality of care.
Neuro-oncologist and OncoHealth Chief Medical Officer Dr. Andrew Norden is on the front-lines of delivering oncology-specific payer solutions. Here are the key lessons he thinks plans need to know to improve their cancer support programs:
1) A siloed approach to reviewing medical and pharmacy treatments presents risk
Today’s cancer treatments increasingly involve multiple drugs and often at least one is an oral medication. In fact, 28% of the FDA oncology approvals in 2022 were for combination therapy regimens1. If your medical and pharmacy benefits are being evaluated separately, with separate utilization management review, you’re risking patient safety and toxicity while missing the chance to reduce spend across the regimen.
2) Sometimes prior authorization will increase costs
Prior authorization gets a bad rap, but our OncoHealth oncologists are on top of the latest literature. Sometimes that means we will review a request and recommend a new treatment, even if it’s more costly, as it may improve the patient’s outcome. Oncologist-led PA reviews allow us to recommend evidence-based options not yet listed in NCCN Guidelines – cancer patients don’t have time to wait on guideline updates. Ensuring the patient is on the best-fit therapy tailored to that cancer patient’s needs irrespective of cost helps improve outcomes while reducing the total cost of care. Lower cost therapy with poorer outcomes can lead to higher spend due to more rapid disease progression, more frequent imaging, and high toxicity costs with added ED visits or hospitalizations.
3) Oncologists should lead peer-to-peer review for cancer treatments
While this seems logical, not all decision support partners utilize oncologists throughout the entire treatment review process. Within a peer-to-peer conversation, oncologists can discuss newly published articles and emerging study outcomes, alternative therapy choices that reduce toxicity or improve survival, or choices that may be clinically identical but less costly for the patient or payer. Our approach has led to a provider approval rating that is consistently greater than 90%.
4) Don’t let your strategy end after prior authorization
Most plans focus solely on utilization management strategies to stem pharmacy and medical costs. If you’re not also proactively supporting your members with cancer, your members’ total cost of care may escalate through increased unplanned ED visits, hospitalizations, diagnostic testing, and even increased spending at the end of life. Provide on-demand care management such as side-effect tracking and management that trigger care interventions to help your members feel supported and avoid the ED.
5) A hidden cost impacting total cost of care: the member’s mental health
A cancer diagnosis increases the risk for anxiety and depression, and prompt treatment makes a difference in terms of patient experience and care utilization. 2 There’s often a months-long wait list for an oncology-trained mental health therapist when one is even available in a community. Access is further exacerbated by routine barriers to care such as transportation and childcare. Offering a virtually delivered oncology-specific therapy service may help close this gap.
6) When questions arise, patients don’t want to bother their doctor
Questions will arise during treatment. Sometimes they happen during business hours. Often they happen at night or on the weekend. In both cases, patients are often reluctant to contact their doctor and be a bother. When questions go unanswered – especially as symptoms begin to escalate – patients end up in the emergency department. Nearly 52% of ED visits are potentially avoidable. 3 A best practice is to offer your members access to convenient 24/7 support and expert advice.
7) End-of-life care planning ensures members’ treatment is consistent with their goals and values
There is often a disconnect between what individuals say they want (less aggressive treatment at end of life) and what is received, which translates to expensive care for plans at end of life. You can help your members access and complete early and proactive end-of-life planning that allows them to create an experience that reflects their goals and needs. Oncology mental health therapists expertly partner with patients and families to translate values into advance care plans. Building a therapeutic relationship over time leads to the trust needed to address these difficult topics resulting in better care and lower costs.
Andrew Norden, MD, MPH, MBA is the Chief Medical Officer at OncoHealth
1 FDA. Oncology (Cancer) / Hematologic Malignancies Approval Notifications
2 Mausbach, B. T., et.al. Health Psychology. doi.org/10.1037/hea0000670
3 Tabriz, A.A., et. al. JAMA Netw Open. Doi:10.1001/jamanetworkopen.2022.50423