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.

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.

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

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.

Timeframe is assigned based on the regimen for adjuvant treatment. Metastatic episodes are defined as four-month periods with renewals.

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.

Jennifer Malin, MD, PhD, serves as a member of the Health Care Payment Learning & Action Network's Clinical Episode Payment Work Group. She is Staff Vice President for Clinical Strategy at Anthem, Inc., where she provides clinical leadership for the enterprise strategy to improve health outcomes of Anthem members, specifically within the specialties of oncology, maternity and infant health, and behavioral health.

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