There are some basic approaches health insurance plans can use to create better odds for cost-efficiency
Biotechnology, new treatments, and clinical trials have advanced cancer therapies significantly over the past decade. A recent article in Health Affairs notes that improvements in cancer therapy in the United States have helped to extend life expectancy by two years.
However, these improvements come at a significant financial cost. In 2011, the United States spent $124 billion on cancer; it is estimated that by 2020, the annual cost will be $207 billion.
The system must develop programs and strategies that allow all patients — in all health plans — to best benefit from current and future advances and innovations in cancer treatment, says Scott Schell, MBA, MD, PhD.
Payers struggle with ensuring that programs are cost-effective while maximizing clinical outcomes.
How can health care organizations ensure that they are on the right track? Here are six things you can do to create an effective cancer care program:
1. Ensure that you have the expertise to manage the types of cancers and patients seen today. Prostate, breast, bladder, colorectal, lung, and melanoma cancers continue to be the most common, and public health analyses project that as the population ages, rates of pancreatic and esophageal cancer and non-Hodgkin’s lymphoma will increase. New therapies for non-small-cell lung cancer and localized prostate cancer are beginning to affect health plans.
Companies must ensure that their systems and protocols adequately manage current needs and predict future requirements so that programs can be adapted when necessary.
New screenings and diagnostics approved by the Centers for Medicare & Medicaid Services also provide opportunities for therapy and compliance. Health plans should keep an eye on pharmacogenomic testing for breast and colon cancers and newly approved screenings for prostate and lung cancer.
As cancer therapy becomes increasingly complex, subspecialists in oncology are playing an increasing role in managing specific tumor types. Health plans today need access to experts in neuro-oncology, lymphomas, leukemias, OB/GYN, and urology. If a managed care organization is lacking in these areas, it can obtain services through outside partners, universities, and specialty vendors.
2. Develop programs to address promising, yet high-cost, biologics. Advancements in cancer treatment include the ability to identify molecular targets specific to certain cancers and the therapies that affect these targets. Decisions on how and when to use these more expensive targeted therapies are challenging, especially when they do not provide superior outcomes when compared to other, lower-cost therapies.
For example, many colon cancer patients without the oncogenes known as wild-type k-ras were treated with therapies targeting k-ras by overenthusiastic oncologists who did not realize that there could be no therapeutic benefit.
This example highlights the need for expert clinical review and assessment to ensure that targeted therapies are being used appropriately and that health plan dollars are spent wisely. Also, expert clinical review controls pharmaceutical companies’ attempts to influence clinical therapy decisions. Strong policies, oversight, and education help ensure that decisions are based on what is best for the patient and the plan.
3. Create strategies and targeted programs to help avoid additional costs. Excluding cancer-specific treatment, the numbers of hospitalizations for cancer patients are often significantly higher than in general health plan member populations. For example, chemotherapy and radiotherapy can impair immune function, increasing risks of infectious complications and sepsis. In patients with other medical comorbidities, such as diabetes or heart disease, holistic management of these diagnoses with cancer therapy minimizes the risk of preventable complications.
The primary goals of cost avoidance should be to:
Health plans will benefit from programs designed to target the common areas of cancer therapy that result in increased hospitalization and poor outcomes. Optimal cancer management programs are collaborative and integrated with all aspects of the patient’s overall health and care. These cancer management programs have reduced hospital days by 50% or more in some programs, in some cases by maintaining focus on keeping patients in remission.
Effective interventions include offering expanded health and wellness programs geared toward these patients, providing targeted education and support through health coaches and nurse case managers, ensuring that proper screenings are conducted, and encouraging appropriate visits to care providers.
4. Empower and educate patients through use of nurse case managers. Cancer care encompasses a range of specialties, therapies, and technologies. However, there is another element that is often more difficult to quantify but that plays a significant role: the effort to inform, educate, and empower patients.
Oncology nurse case managers effectively support and empower cancer patients through their diagnosis and treatment. These case managers assist with coordinating care; educating patients, caregivers, and family members; facilitating communication between patients and providers; and enabling patients to make the transition from treatment to hospice in a thoughtful and dignified manner.
Patients with cancer experience a range of emotions, fears, and concerns. When these emotions are inadequately understood and addressed, patients become less engaged in their care and are less likely to adhere to therapy or manage other comorbid conditions.
The most successful cancer programs assign oncology nurse case managers for each patient, providing psychosocial support to them and their families. Health plans utilizing nurse case managers include major national plans like UnitedHealth as well as regional plans such as Oxford Health Plans and Blue Cross Blue Shield of Michigan.
Oncology nurse managers, who can be reached by phone at any hour, assist with management of side effects in clinically important areas such as dehydration, pain, nausea, and vomiting. These nurses can make an in-home visit for complex cases, make frequent phone calls to patients and family, and find resources for wigs, prostheses, and reconstructive and rehabilitation therapies. Health plans recognize that many of the new patients they are likely to be covering soon under the Affordable Care Act may not have had access to routine medical care. These patients will be unfamiliar with the health care system and need education and guidance.
Nurse case managers and health coaches, who maintain contact with patients, can play a vital role in providing this guidance and education.
Nurse case managers support end-of-life planning as well. Health plans need formal programs and resources to help patients address issues such as advanced directives, DNR orders, hospice care, extreme medical procedures, and so on.
5. Determine the scope of the program. During the late 1980s and into the early 1990s, many health plans outsourced cancer care programs to ensure a dedicated focus and to create efficiencies. During the last 10 years, many health plans brought cancer programs back in-house to control cost.
The high cost of certain types of cancers and the need for highly specialized experts and care is causing some health plans to once again consider carving out at least a portion of their cancer programs to an outside organization. Alere and other companies are noting an increase in requests via RFPs for carving out higher cost cancer programs.
The first step to determine the value of such an approach is to examine current data. What types of cancers does the organization see most often? Which are the most costly? What types of specialists are within the organization? Where are there gaps?
6. Meet challenges head-on. The aging population, targeted therapies, and an expanding epidemic of comorbidities mean health plans are faced with challenges when it comes to managing members with cancer. These include:
Health plans must choose between a proactive or a reactive approach.
Many health plans today recognize that a proactive approach, including a team that includes clinical experts with the experience needed to provide optimal outcomes while managing costs, is best for ensuring fiscal and clinical outcomes. This team should work collaboratively, with goals aligned, to ensure that all who deliver care have access to relevant patient information when needed. We must develop programs and strategies that allow all patients — in all health plans — to best benefit from current and future advances and innovations.