July 21, 2015
Co-presenters answer participants’ questions on alternative payment models for oncology care that were not answered during the webinar.
Jennifer Malin, MD, PhD - Anthem
We don’t have an episode. We do a case management fee. Our care coordination fee is on a monthly basis. There is no defined episode.
Have you found evidence-based medicine to support current genomic testing relative to cancer treatment? What impact do you see genomics/ proteomics having on the treatment protocols?
Therapy targeted on specific biomarkers goes back 30 years, such as the use of Tamoxifen for hormone receptor-positive breast cancer. So this isn’t new, it is just accelerating. There is no current evidence for doing large gene panels to see if a tumor has one of 100 different variations. But for specific cancers, there are specific mutations that can lead to better treatment. They are included in our pathways.
Is there any preliminary data on the impact of the program on global costs, i.e. reduction of Emergency Department (ED) and hospital admission?
It is too early to see.
How did Anthem work with providers who may have pathways programs with other insurers in terms of working with multiple IT systems?
Unfortunately, for payment of claims, data must flow into our IT system. However, we have combined the prior authorization process with the claims process. By combining these two processes into one step we have decreased the administrative burden.
Lee Newcomer, MD, MHA - UnitedHealthcare
This is proprietary information.
It seems the drug choice is based on a doctor’s opinion; what if evidence shows a different drug is better? Is there any thought to patient choice with knowledge of what all the options are for them versus the doctor making a recommendation?
We allow the physicians to make the choice. In all situations we’ve seen, the regimens are very comparable for results. We haven’t seen a physician choose an inferior regimen. Physicians are allowed to make a change anytime based on patient preference.
What are the differences in how you defined the episodes for both models? And what is the timeframe for both models? And what is the timeframe for episodes in each model?
Timeframe is assigned based on the regimen for adjuvant treatment. Metastatic episodes are defined as four-month periods with renewals.
Have either of the payers found evidence based medicine to support current genomic testing relative to cancer treatment? What impact do you see genomics/proteomics having on the treatment protocols?
There are specific cancers with specific genomic tests that are helpful. For example, HER2 for breast cancer and ALK for lung cancer. Like any new evidence, they should be incorporated into the protocols if and only if the evidence shows unequivocal responses.