Actionable data analytics in oncology: are we there yet?

To operate under a new value-based paradigm, oncology providers must develop the capability to aggregate, analyze, measure, and report their value proposition--that is, their outcomes and associated costs. How are oncology providers positioned currently to perform these functions in a manner that is actionable? What is the current state of analytic capabilities in oncology? Are oncology providers prepared? This line of inquiry was the basis for the 2013 Cancer Center Business Summit annual industry research survey. This article reports on the key findings and implications of the 2013 research survey with regard to data analytic capabilities in the oncology sector. The essential finding from the study is that only a small number of oncology providers (7%) currently possess the analytic tools and capabilities necessary to satisfy internal and external demands for aggregating and reporting clinical outcome and economic data. However there is an expectation that a majority of oncology providers (60%) will have developed such capabilities within the next 2 years.

Payers working collaboratively with providers to adopt clinical pathways and new care delivery models.

The authors found that payers were realistic and pragmatic in identifying challenges to implementing new oncology care delivery models, identifying provider alignment and infrastructure/data acquisition as the two most significant challenges, followed by care coordination, provider incentives, and organizational structure.

Rapid expansion of new oncology care delivery payment models: results from a payer survey.

BACKGROUND: Oncology practices are seeking to adapt to new care delivery models, including accountable care organizations (ACOs), patient-centered medical homes (PCMHs) in oncology, and oncology pathways, as well as new payment models, such as bundled payments or pay-for-performance contracts. OBJECTIVE: Our survey sought to determine which payment models and care delivery models payers view as the most viable and the most potentially impactful in managing and reducing the cost of cancer care. METHODS: We conducted an online national survey of 49 payers, including 19 medical directors and 30 pharmacy directors, representing more than 100 million covered lives within national and regional plans, using a validated instrument comprised of approximately 120 questions. The survey was administered using the SurveyGizmo website. It was initiated on July 10, 2012, and completed on July 25, 2012. The survey included open- and closed-ended questions and probed payers about models of care that they, in collaboration with providers, are implementing or supporting to improve the quality of cancer care and to reduce the associated costs. RESULTS: Payers are rapidly moving to implement new reimbursement models to support new care delivery models, including ACOs and PCMHs. Based on the results of this survey, a minority of payers are experimenting with new oncology payment models, but most payers are evaluating various models, including bundled payments, capitation, shared savings, and pay for performance. Of the payers in this survey, 39% have already implemented oncology pathways, and 59% who have not already done so are planning to implement pathways in 2 years. Input from local oncology experts is an important resource for pathway development, and a substantial majority (95%) of payers will use pathways to address earlier initiation of palliative care discussions where appropriate. CONCLUSION: Payers anticipate that there will be a rapid expansion of the use of innovative approaches to oncology cost management over the next 2 years. As payers and their network providers gain more experience in collaborative care delivery, it is expected that demonstration of cost-savings will become more robust and convincing, and a variety of approaches will become more widely adopted.

Trends in biologic therapies for rheumatoid arthritis: results from a survey of payers and providers.

BACKGROUND: Advances in therapies for rheumatoid arthritis (RA), particularly biologics, have transformed the treatment paradigm for RA. However, the associated costs of these therapies result in a significant economic burden on the healthcare system. As a chronic disease requiring lifelong treatment, most health plans now position RA drugs as a high-priority therapeutic category. OBJECTIVE: To identify provider and payer practices and perceptions regarding coverage of RA biologics in the current marketplace, as well as emerging trends in reimbursement practices. METHOD: In November 2011, Reimbursement Intelligence, a healthcare research company, collected and analyzed quantitative and qualitative data via parallel-structure online surveys of 100 rheumatologists and 50 health plan payers (medical and pharmacy directors) who represent more than 80 million covered lives. The surveys included approximately 150 questions, and the surveys were designed to force a response for each question. RESULTS: Payers reported using tier placement, prior authorization, and contracting in determining coverage strategies for RA biologics. Among providers, experience with older RA agents remains the key driver for the choice of a biologic agent. A majority of payers and providers (68% and 54%, respectively) reported that they did not anticipate a change in the way their plans would manage biologics over the next 2 to 4 years. Payers' responses indicated uncertainty about how therapeutic positioning of newer, small-molecule drugs at price parity to biologics would affect the current reimbursement landscape. Survey responses show that approval of an indication for early treatment of RA is not likely to change the prescribing and reimbursement landscape for RA biologics. This survey further shows that payers and providers are generally aligned in terms of perceptions of current and future treatments for RA. CONCLUSION: Advances in RA therapies allow patients increasing options for effective disease management. However, the high cost of biologic therapies and the need for lifelong treatment raise economic concerns. Payer satisfaction with current therapies and uncertainty about added value of new therapies will create challenges for new medications coming to market.

Emerging trends in cancer care: health plans' and pharmacy benefit managers' perspectives on changing care models.

BACKGROUND: Cancer care in the United States is being transformed by a number of medical and economic trends, including rising drug costs, increasing availability of targeted therapies and oral oncolytic agents, healthcare reform legislation, changing reimbursement practices, a growing emphasis on comparative effectiveness research (CER), the emerging role of accountable care organizations (ACOs), and the increased role of personalization of cancer care. OBJECTIVE: To examine the attitudes of health plan payers and pharmacy benefit managers (PBMs) toward recent changes in cancer care, current cost-management strategies, and anticipated changes in oncology practice during the next 5 years. METHODS: An online survey with approximately 200 questions was conducted by Reimbursement Intelligence in 2011. The survey was completed by 24 medical directors and 31 pharmacy directors from US national and regional health plans and 8 PBMs. All respondents are part of a proprietary panel of managed care decision makers and are members of the Pharmacy and Therapeutics Committees of their respective plans, which together manage more than 150 million lives. Survey respondents received an honorarium for completing the survey. The survey included quantitative and qualitative questions about recent developments in oncology management, such as the impact on their plans or PBMs of healthcare reform, quality improvement initiatives, changes in reimbursement and financial incentives, use of targeted and oral oncolytics, and personalized medicine. Respondents were treated as 1 group, because there were no evident differences in responses between medical and pharmacy directors or PBMs. RESULTS: Overall, survey respondents expressed interest in monitoring and controlling the costs of cancer therapy, and they anticipated increased use of specialty pharmacy for oncology drugs. When clinical outcomes are similar for oral oncolytics and injectable treatments, 93% prefer the oral agents, which are covered under the specialty tier by 59% of the plans. The use of the National Comprehensive Cancer Network practice guidelines for coverage and reimbursement of oncologic agents is reported as "very frequent" by 10% of survey respondents, "frequent" by 21%, and "moderately frequent" by 7%. Most (66%) respondents believe that it is probable and 3% believe it is highly probable that healthcare reform will help to control oncology treatment costs, although 59% also predict an increase in utilization restrictions and 48% predict more stringent comparative effectiveness evidence requirements. The survey reveals a considerable uncertainty among health plans and PBMs about the eventual impact of ACOs on oncology care. Although 82% of those surveyed believe that measures such as increasing adherence to evidence-based treatments will achieve cost-savings, nearly half (48%) had no plans to use such measures. CONCLUSIONS: Recent trends in healthcare legislation, rising drug costs, and changing reimbursement practices are poised to significantly alter conventional models of cancer care delivery and payment. The results of this survey indicate that health plans and PBMs anticipate greater use of evidence-based management strategies, including CER, quality initiatives, and biomarker testing for appropriate cancer therapy selection. In addition, they anticipate greater focus on cost control, with a greater role for utilization management and increased patient cost-sharing. Finally, there is a high level of uncertainty among plans and PBMs about the eventual impact of ACOs and other aspects of healthcare reform on oncology practice.

Review of strategies to enhance outcomes for patients with type 2 diabetes: payers' perspective.

BACKGROUND: Diabetes and its clinical consequences exact a great toll on patients and on society in terms of its effects on morbidity and mortality and its staggering economic impact. OBJECTIVE: To review various programs and strategies that aim at enhancing adherence to antihyperglycemic therapy and suggest the best approach to improving patient outcomes and reducing healthcare costs. DISCUSSION: Treatment goals for patients with diabetes have been defined, and multiple safe and effective medications are available. Nevertheless, the majority of patients with diabetes fail to achieve treatment goals, because of difficulty with adherence to medication regimens and lifestyle modifications, and because of economic barriers. This article discusses various initiatives developed to improve patient outcomes, including consumer-driven health plans and wellness and prevention programs. Furthermore, economic incentives to patients, such as value-based insurance design, may increase adherence; nevertheless, evidence suggests that such programs alone provide only modest gains. Primary providers in disease management programs can include nurses, case managers, or pharmacists. Supportive interventions across several modalities have been shown to be effective. CONCLUSION: An approach that uses a combination of strategies designed to impact patients' health-related behaviors across a variety of modalities may help to improve outcomes and reduce costs. Additional novel, innovative interdisciplinary initiatives are necessary to effect meaningful change that can facilitate improved health outcomes for patients with diabetes and maximize cost-effectiveness approaches for payers.

Obesity: effective treatment requires change in payers' perspective.

BACKGROUND: Obesity is an increasing problem in the United States, and the health problems attributed to it have a significant economic impact on the healthcare system, as well as on patients' quality of life. In addition, childhood obesity is increasingly becoming a prominent diagnosis. OBJECTIVE: To identify physician and payer reactions to the profiles of 4 new obesity products in development and the potential that these will be prescribed by physicians and reimbursed by payers. This article examines payers' and physicians' perspectives in effective treatment options for this epidemic. METHOD: A 2008 online survey conducted by Reimbursement Intelligence was completed by 42 physicians who are advisors to Pharmacy & Therapeutics Committees and see an average of 435 obese patients monthly, as well as 17 payers who represent more than 100 million covered lives. This research was double blinded to conceal product and client identification. Qualitative and quantitative data were collected from the survey responses. RESULTS: Based on the physician and payer survey responses, morbid obesity is expected to grow in the next 2 years. About 80% of morbidly obese patients have type 2 diabetes, but more than 75% of payers do not track patients who are obese, morbidly obese, or those with the metabolic syndrome. Despite its effect on business productivity and the cost of care, healthcare professionals and payers continue to have varying perspectives related to its prevention and treatment. Physicians would like to have more treatment options, but payers perceive them as ineffective and find the safety and adverse effect profiles unfavorable. CONCLUSION: There is a clear need for multiple treatment alternatives to combat obesity that include plan member access to weight-loss options, such as prescription medications and bariatric surgery. There needs to be an increase in educational support from manufacturers of products for obesity, as well as increased awareness of products in the pipeline.