Payment Reform Models in Oncology Care & Management

Authored by Mary SeeryCancer Treatment Centers of America National Director of Business Markets

With everything going on in the world of politics, policy and health care, I am certain that oncology payment reform is not on the top of your mind – but maybe it should be! Years ago when I began working for a large health care system focused on oncology, I would not have bet (and I am a bettor), that payment reform would so quickly have reached the complex world of oncology – but it has and it should be on your radar. Here’s why:

While Medicare might be the most recognized oncology payment model pilot running nationally, the big commercial payers as well as providers big and small are dipping their toes in the water of understanding how oncology payment reform can reduce cost and improve quality of care for one of the most expensive diseases to treat. Even physician groups and health systems have begun focusing on the topic.

Alternative Payment Models or APMs take many forms, names and claims. They include or can be tied into different delivery models including specialty Accountable Care Organizations (ACOs) and Oncology Medical Homes (OMHs). Most reward the providers for following certain defined pathways that are thought to provide the most effective, least toxic and least costly treatment. While I agree that there is value to this approach in orthopedic and simple cardiac procedures, it certainly gets more difficult with the complex, individualized treatment of cancer. Advancements in precision medicine are beginning to gain traction but remain largely unrecognized in reimbursement approaches. Are these models ready to make room for advancements or will they insist on the reliance of predetermined treatment pathways?

To muddy the waters a bit more, payers and providers alike are piloting episode-based payments and/or bundled pricing for either certain aspects of treatment or all facets of cancer treatment. Speaking from the provider side, my opinion is that this can be a very hard road to maneuver down. It’s a shared risk approach which can be tempered by more prevalent and predictable cancers, but as a former colleague always said to me “every cancer is like a snowflake”.

So the key question today is “are these approaches working?” Some commercial payers are reporting savings, but we are unclear as to whether the savings are built off a loss for the provider. Providers tend to receive only a nominal fee for participation in their programs. That fee can vary from approximately $160 in CMMI’s Oncology Care Model (OCM) to a reported $350/month in a commercial pilot. While this is not an apples to apples comparison of the programs, it just illustrates that payment variation still exists and will continue to exist between government and commercial payers. With MACRA likely decreasing physician reimbursement over the next decade, how will the providers of care fare in the future?

One thing is certain – everything is changing and it will be a race to the finish to see what APMs make the most sense. You, as employers, carry the power to help guide your employees through what works best by being informed and designing their plans to help them get the best care at the appropriate location at the best price for you. I am looking forward to working with you and FLHCC this year on the oncology payment model project.

---

Mary Seery is the National Director of Business Markets for Cancer Treatment Centers of America (CTCA). She leads the efforts to increase patient access to all CTCA hospitals through direct contracting with employers and insurance networks. She and her team are responsible for leading the development of key national large employer, payer, and influencer relationships as well as health care intermediary and regulatory relationships.

Mary has over 18 years’ experience in healthcare. Prior to joining CTCA, Mary has worked across many regions of the country with some of the largest pharmaceutical companies to commercialize new medications and increase market receptivity and use. Mary directed regional business expansion while with Medical Resources, Inc. She has also led new business marketing and growth through her time as Marketing and Sales Director at Windy City Anesthesia.

Mrs. Seery received her Bachelor of Arts degree in Public Relations from the University of Illinois Chicago. She currently sits of the National Board of Directors for the Association of Corporate Health Risk Management and is a Transparency Committee Member for the Greater Philadelphia Business Coalition on Health. Mary is also a member of the National Health Leadership Council. She also volunteers for her town, the Village of Orland Park, on various Committees and Commissions.

 

Mary Seery, National Director of Business Markets for Cancer Treatment Centers of America (CTCA)2/20/2017

How to Support Your Employees Struggling to Lose Weight

Losing weight and keeping it off is not easy. Many people who struggle with weight experience ups and downs, as they try different diet and exercise plans that either don't work or cannot be maintained. This struggle can be filled with frustration and feelings of failure. Patients may blame themselves for having a lack of willpower or discipline to lose weight; however for some patients, diet and exercise alone may not be enough to lose weight and keep it off. The fact is – obesity isn’t a lifestyle choice, it has been defined as a disease by several professional healthcare societies, including the American Medical Association. 

We at Orexigen Therapeutics® are very familiar with this disease as our global focus is on developing medicines for patients struggling with their weight. We are dedicated to mitigating obesity and are looking to the employer community to help us support their members who are struggling to achieve their weight loss goals. To that end, there are four important points that employers may want to consider to help their employees/patients:

Obesity is a rapidly growing global health epidemic: Obesity is a reality for most Americans and there is no end in sight. By 2030, the percentage of Americans who struggle with obesity could reach 51 percent, underscoring the need for effective treatment regimens today.(i)

Obesity remains undertreated, particularly when compared to other diseases:About 110 million adults in the US meet recommendations for anti-obesity pharmacotherapy; however, only 3% of those adults are being treated with a prescription weight loss therapy.(ii) This is a large difference compared to the 8.4% of US adults with type 2 diabetes, of which 86% receiving pharmacotherapy treatment.(iii)

Considering the costs associated with obesity is an important factor when making health care benefit decisions: Obesity has broad consequences from an employer perspective, including(iv)

• Decreased work productivity, costing employers $73 Billion annually

• Increased presenteeism & absenteeism, costing $766 per employee struggling with obesity annually

Branded obesity medications can be an effective treatment for those struggling to lose or maintain weight, in addition to diet and exercise: There are several reasons why(v):

• Pharmacotherapy is part of many professional guidelines to treat obesity.(vi)

• These branded anti-obesity medications may only be made available through your pharmacy benefit coverage when you elect an obesity rider as part of your annual health benefits selection process.

• It is important to remember that even modest reductions in weight loss can result in significant health benefits and savings to patients, employers, and the healthcare system.

As you review your annual health benefits package, please consider adopting an obesity benefit rider, which provides employees with the opportunity to help their struggle with obesity today. The inclusion of prescription oral obesity medications as a new solution for employees may positively reduce your costs and improve your employees’ overall health and productivity.

---

(i) http://obesitycampaign.org/obesity_facts.asp Trust for America's Health F as in Fat How Obesity Threatens America's Future

(ii) Thomas CE et al. Obesity. 2016;24:1955-1961; Patients with BMI of 30+, BMI 27-29 with co-morbidities. Orexigen Segmentation Research based on CDC data. National Center for Health Statistics: Obesity/Overweight. 2015. https://www.cdc.gov/nchs/fastats/obesity-overweight.htm. Accessed on December 27, 2016

(iii) Thomas CE et al. Obesity. 2016;24:1955-1961

(iv) J Occup Environ Med. 2010 Oct;52(10):971-6; J Occup Environ Med. 2014 Nov;56(11):1120-7; State of Obesity 

(v) Thomas CE et al. Obesity. 2016;24:1955-1961.

(vi) American Association of Family Physicians (AAFP) - Diagnosis and Management of Obesity monograph (2013)

American Heart Association (AHA)/American College of Cardiology (ACC)/The Obesity Society (TOS) - Guideline for the Management of Overweight and Obesity in Adults (2014)

American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE) - Diagnostic Algorithm for the Disease of Obesity (updated 2016)

Obesity Medicine Association (OMA) - Obesity Algorithm (updated 2016) 

The Endocrine Society - Pharmacologic Management of Obesity: An Endocrine Society Clinical Practice Guideline (2015) 

Tom Eastep, Senior Health Science Associate, Orexigen 6/7/2017

8 Questions to Ask Your Health Plan About Employer Reporting

At least two decades of statistics suggest there is an inverse relationship between employer health costs and employee health status. After all, research from the Kaiser Family Foundation shows premiums for employer-sponsored health insurance increased 203 percent between 1999 and 2015.2 Contemporaneously, the prevalence of employee obesity, diabetes, high blood pressure and chronic illness has grown exponentially.

This dynamic has left many employers, and especially their finance and human resources staff, feeling powerless.

At Geneia, we strongly believe there is a compelling opportunity for employers to reverse this dynamic and improve the quality and cost of healthcare. It begins with timely data and actionable insights and employer willingness to use this information to hold health plans accountable for the return on investment on their healthcare spend.

In our experience, there are eight questions the savviest employers pose to their health plan about reporting:

1. Timeliness:

How often is the data updated and how frequently do your employer clients access the information?

Employers’ access to claims information often lags by months. Employers need access to real-time clinical and claims information to impact healthcare spend this year and make impactful benefit changes for the year ahead. The frequency that employers access health plan reporting is a bellwether indicator of how often the data is refreshed and how relevant the information is.

2. Usability:

Is your reporting self-service, readily understood and actionable by existing human resources staff, and comprised of drill-down capabilities for further exploration?

Human resources staff juggle many competing demands, and most have limited time to focus on employee benefits and do not have analytics expertise. Therefore, it is imperative that health plan reporting is on-demand, available precisely when employers want it, and actionable by existing staff.

Furthermore, rather than needing to request ad-hoc reports from their health plan or broker, employers need easy-to-use dashboards with drill-down capabilities to, for example, learn
more about the cost drivers for high-risk employees who have not seen their primary care physician in the past 12 months and preventive care compliance for diabetics.

3. At-Risk Employees:

What’s the risk score for my at-risk employees and how has their risk score changed as the result of the health plan’s case and disease management programs?

At a high level, the goals for health plan engagement are to identify the risk status of employees and work to maintain the current status and prevent further deterioration. In other words,

• For Healthy Employees: Keep them healthy
• For At-Risk Employees: Prevent or delay chronic disease
• For Chronically-Ill Employees: Slow or halt disease progression

The savviest employers not only know which employees have been identified for health plan case and disease management programs and the percentage who are actually participating, but more importantly, how the risk score has changed for the engaged and non-engaged populations. The change in risk score is the single best indicator of the effectiveness of these programs.

4. Rising-Risk Employees:

How do you predict which employees are likely to get sick and how do you prevent them from developing chronic disease?

Increasingly, predictive analytics allow health plans to successfully identify which members are likely to become sick in the next 12 to 24 months and then intervene to prevent chronic illness. For example, identifying the pre-diabetics within an employee population and combining this information with preventive care compliance and medication adherence data enables health plans to effectively direct care management resources.

5. High-Risk Employees:

How do you incorporate biometric data to mitigate disease progression?

For the highest-risk employees, studies have proven the effectiveness of capturing real-time changes in biometric data such as weight, blood pressure and pulse oxygen, and integrating this data with additional clinical and claims information to create a comprehensive 360-view.

A Geneia study of health plan members diagnosed with heart failure demonstrated that remote monitoring facilitated earlier interventions by the member’s care team and prevented avoidable hospitalizations and disease progression. In short, the heart failure patients in our study fared much better than the control group.

• Risk Score Stabilized: A 2 percent increase in the study group compared to a 31 percent increase in the control group – indicating a slowing of disease progression for participants.
• Hospital Admissions: With a net 45 percent reduction in acute hospital admissions, they spent far less time in the hospital.
• Medication Adherence: Increased by 37 percent.

6. Disease and Condition Prevalence:

Which conditions have the highest per member per month costs for my employees, and of those conditions, which can be improved with behavior change and wellness initiatives?

To make more of a cost and quality impact, employers’ wellness investments increasingly are targeted to particular groups of employees. This means employers will need timely access to data such as disease and condition prevalence among their employees, associated costs, and treating providers. The savviest employers have begun directing their wellness resources to the conditions most amenable to behavior change.

7. Sub-Population Trends:

What are the readmission, hospitalization and emergency department trends by sub-populations such as the healthy, at-risk, and chronically-ill?

Since we know certain sub-populations are higher utilizers of avoidable healthcare services, the usefulness of aggregate numbers is limited. Therefore, it’s imperative to have access
to sub-population trend data to more effectively manage the cost and quality of care.

8. Pharmacy:

How accurate are your estimates of specialty pharmacy costs and how do you impact employee site-of-service for specialty pharmacy?

Without a doubt, specialty pharmacy costs are a major driver of health costs. The estimated number of Americans with annual drug costs greater than $50,000 increased 63 percent
in 2014, and current trends suggest specialty drug spending will total $400 billion by 2020, or 9.1 percent of national health spending.3

As the steward of employer health spending, health plans will need to do more to estimate and control specialty pharmacy costs, including evaluating the cost and quality by site-of-service and directing employees to higher value care. The savviest employers are already asking for this level of detailed information.

Health plans may be surprised to learn that nearly all employers already know advanced analytics help them make better healthcare decisions, and 83 percent say advanced analytics is the only way to lower healthcare costs and improve results. A recent survey by the National Alliance of Healthcare Purchaser Coalitions and Geneia also found:

• 90 percent of employers say near-real-time data is imperative to realizing cost savings
• 94 percent agree that “healthcare analytics can help me evaluate which wellness programs would be most effective to offer to my employees”
• 83 percent agree that using advanced analytics to understand how your employees use healthcare services, who your high-risk employees are and how to intervene effectively is the only way to lower costs and improve financial results

In the face of increasing costs and declining employee health, employers have had to become more skilled at asking the right questions and holding their health plans accountable for the answers. The most innovative health plans know this, and are already providing their employer customers with actionable and timely reporting enhanced with advanced analytics.

---

1 Centers for Medicare and Medicaid Services, National Health Expenditure Projections 2012–2022.
2 Kaiser Family Foundation/Health Research & Educational Trust (HRET) 2016 Employer Health Benefits Survey. 
3 Pew Charitable Trust, Specialty Drugs and Health Care Costs, November 2015.

- See more at: https://www.geneia.com/blog/2016/december/eight-questions-to-ask-your-health-plan-about-employer-reporting#sthash.OHXjCdb0.dpuf

Heather Lavoie, Chief Strategy Officer, Geneia 1/5/2017