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Controlling Costs of Oncology Care and Drugs


Tim Casey

Las Vegas—When evaluating models to manage oncology programs, payers and providers must work together and consider areas such as transparency, collaboration, involvement of physicians, negotiations, and strategic direction, according to Dawn Holcombe, MBA, MA, president of DGH Consulting and executive director of the Connecticut Oncology Association. Ms. Holcombe spoke at the Fall Managed Care Forum during a session titled Oncology Management Trends: Who, How, Why and What Questions to Ask. Ms. Holcombe said payers and physicians have different goals when it comes to evaluating options. Payers want to reduce variation, decrease costs, and have a good business partner. Physicians put the patients’ needs first and also care about evidence-based care and medical decision-making provisions. Ms. Holcombe discussed the 2008 Oncology Trend Report, a cross-industry national survey sponsored by Genentech Inc and executed by Kikaku America International that interviewed managed care professionals, specialty pharmacy professionals, oncologists, and oncology practice administrators and billing managers. Of the 90 managed care professionals surveyed, 79% expected the management of cancer care will increase in the pharmacy benefit; 61% were neutral or not worried about dropping reimbursements and losing medical directors in their network; 43% expected to require specialty pharmacy for specific drugs in the next 12 months; 35% to 45% anticipated changes affecting medical director drug choices and utilization; 67% believed a disease management program would be effective in managing cancer care costs; and 72% offered case management to patients. The 42 specialty pharmacy professionals interviewed said the management of oncology drugs by specialty pharmacy providers and pharmacy benefit managers accounted for 21% of their organization’s total revenue and 16% of total prescription volume; 60% of cancer-related revenue for specialty pharmacies was generated by distributing cancer medications to patients for self- or home administration; oral cancer medications accounted for 26% of all cancer-related prescriptions distributed through specialty pharmacy, including 33% of these prescriptions for self-injected cancer therapies, 16% for adjunctive cancer therapies, 13% for office-based infusions, and 12% for office-based injections; 81% of the organizations provided patient education and disease management; 74% of the organizations provided compliance and persistence programs; and 69% of the organizations provided patient care coordination programs. Of the 142 oncologists surveyed, 64% said their workload had increased in the previous year; 39% said their income had decreased in the previous 2 years; 58% said they identified therapies that led to revenue loss; and 69% said they considered referring patients to a hospital when a therapy results in a financial loss for their practice. The 2008 survey also included 60 oncology administrators who shared their views and approaches to practice management, billing, and reimbursement: 60% said payer contracts were mostly favorable, 23% said they were not favorable, and 17% said they did not know; 19% did not negotiate fee schedules; 35% tried to negotiate fee schedules but were generally not successful; 21% did not know contract collectibles; and 21% knew the contract collectibles but did not know if they were paid correctly. Ms. Holcombe also spoke about the 2010 Oncology Trend Report, which was sponsored by sanofi-aventis, executed by Kikaku America International, and included 80 managed care professionals and 163 oncologists. According to the managed care professionals, 73.5% of the cancer spending in their organizations is in the medical benefit, but 52.5% of those surveyed said the spending would increase in the pharmacy benefit. In addition, 9.7% of the cancer spending is in oral drugs and 35.4% of the respondents said they had a preferred relationship with at least 1 specialty pharmacies in regard to cancer drugs. Of the managed care professionals, 55.1% said they encouraged but did not require the use of specialty pharmacy. In terms of oncology management measures, 46.3% required step therapy, 46.3% required lab values, 48.7% required prior authorization rules toward preferred agents, 38.8% required compendia positioning, 30% had collaborative relationships with oncologists, and 40% planned to develop relationships with oncologists. Of the oncologists surveyed, 49.7% used electronic medical records but 42.5% did not collect data. In addition, 28.6% said they felt unable to negotiate fees with payers, 57.9% said they felt they were able to negotiate with limited success, and 63.2% identified revenue losses for treatments. Furthermore, 41.1% expected an affiliation or alliance change in the coming years. Ms. Holcombe mentioned several options for oncology management, including drug management, disease management, and specialty pharmacy/pharmaceutical benefit. Drug management is primarily focused on preferred product pricing, formularies, and authorization processes and can lead to savings but has a limited effect on oncology spending, according to Ms. Holcombe. Meanwhile, disease management is focused on managing symptoms and side effects of oncology treatments and disease. However, Ms. Holcombe said savings have not been proven in the long term, there is a limited effect on oncology spending, and programs have led to patient confusion. The emphasis of specialty pharmacy/pharmaceutical benefit is on shifting oncology care to the pharmaceutical benefit and/or the provision of drugs through specialty pharmacy. Medical doctors order, receive, store, provide, and distribute the drugs. Ms. Holcombe said the savings are debatable, and there is a limited effect on oncology spending. When designing with an oncology management strategy, Ms. Holcombe stressed the importance of the collaboration between medical directors and managed care organizations as well as size/affiliations, quality, overhead, and the full continuum of care. She added that oncology management could provide the right care at the right time in the right setting and that reducing variation could have value for all stakeholders.

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