The Problem of Cancer Drugs Costs: A Payer Perspective.

Chemotherapy and supportive drugs constitute 70% of a cancer patient's medical costs during active therapy. Payers use several approaches to keep those costs affordable including paying lower margins for "buy and bill" oncologists, prior authorization, pathways, or performance-based compensation. Payers also utilize financial tools such as deductibles, copayments, or coinsurance to shift more of the cost of health care coverage to employees or the insured. The strengths and weaknesses of those approaches are reviewed in this article. Policy changes that address drug protection from competition or negotiation, monopoly status of health care systems, and Food and Drug Administration approval of new medications will affect how effective any payer strategy will be in the future.

Policy Challenges and Opportunities to Address Changing Paradigms in Cancer Care Delivery.

Multiple factors are forcing the healthcare delivery system to change. A movement toward value-based payment models is shifting these systems to team-based integration and coordination of care for better efficiencies and outcomes. Workforce shortages are stressing access and quality of care for patients with cancer and survivors, and their families and caregivers. Innovative therapies are expensive, forcing payers and employers to prioritize resources. Patients are advocating for care models centered on their needs rather than those of providers. In response, payment policies have recently focused on the promotion of alternative payment models that incentivize coordinated, high-quality care with consideration for value and controlling the increasing overall costs associated with cancer and its treatment. Given the multitude of factors confounding cancer care, NCCN convened a multistakeholder working group to examine the challenges and opportunities presented by changing paradigms in cancer care delivery. The group identified key challenges and developed policy recommendations to address 4 high-visibility topics in cancer care delivery. The findings and recommendations were then presented at the NCCN Policy Summit: Policy Challenges and Opportunities to Address Changing Paradigms in Cancer Care Delivery in September 2018, and multistakeholder roundtable panel discussions explored these findings and recommendations along with additional items. This article encapsulates the discussion from the NCCN Working Group meetings and the NCCN Policy Summit, including multistakeholder policy recommendations on delivery issues in cancer care designed to help inform national policies moving forward.

How Should We Intervene on the Financial Toxicity of Cancer Care? One Shot, Four Perspectives.

The median price of a month of chemotherapy has increased by an order of magnitude during the past 20 years, far exceeding inflation over the same period. Along with rising prices, increases in cost sharing have forced patients to directly shoulder a greater portion of those costs, resulting in undue financial burden and, in some cases, cost-related nonadherence to treatment. What can we do to intervene on treatment-related financial toxicity of patients? No one party can single-handedly solve the problem, and the solution must be multifaceted and creative. A productive discussion of the problem must avoid casting blame and, instead, must look inward for concrete starting points toward improvement in the affordability and value of cancer care. With these points in mind, the authors-representatives from the pharmaceutical industry, insurance providers, oncologists, and patient advocacy-have each been asked to respond with a practical answer to the provocative hypothetical question, "If you could propose one thing, and one thing only, in terms of an action or change by the constituency you represent in this discussion, what would that be?"

Transforming Prior Authorization to Decision Support.

PURPOSE: To evaluate a computer-based prior authorization system that was designed to include and test two new concepts for physician review: (1) the tool would minimize denials by providing real-time decision support with alternative options if the original request was noncompliant, and (2) the tool would collect sufficient information to create a patient registry. METHODS: A new prior authorization tool incorporating real-time decision support was tested with a large national payer. The tool used the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology as the content for decision making. Physicians were asked to submit the minimal amount of clinical data necessary to reach a treatment-decision node within the National Comprehensive Cancer Network Guidelines. To minimize denials, all available recommended treatments were displayed for physician consideration and immediate authorization was granted for any compliant selection. RESULTS: During a 1-year pilot in a Florida commercial health plan, 4,272 eligible cases were reviewed with only 42 denials. Chemotherapy drug costs for the prior authorization pilot were compared with a similar time period in the previous year for the state of Florida, as well as for the Southeast region and for the nation, which served as controls. The percentage change between the time periods was -9% in Florida, 10% for the national costs, and 11% for the Southeast region costs. The difference between the regional increase and the Florida decrease represented a savings of $5.3 million dollars for the state of Florida in 1 year. CONCLUSION: There is significant opportunity to reduce the costs of therapy while being compliant with nationally accepted guidelines for cancer chemotherapy.

The patient-centered medical home in oncology: from concept to reality.

In recent years, the cost of providing quality cancer care has been subject to an epic escalation causing concerns on the verge of a health care crisis. Innovative patient-management models in oncology based on patient-centered medical home (PCMH) principles, coupled with alternative payments to traditional fee for service (FFS), such as bundled and episodes payment are now showing evidence of effectiveness. These efforts have the potential to bend the cost curve while also improving quality of care and patient satisfaction. However, going forward with FFS alternatives, there are several performance-based payment options with an array of financial risks and rewards. Most novel payment options convey a greater financial risk and accountability on the provider. Therefore, the oncology medical home (OMH) can be a way to mitigate some financial risks by sharing savings with the payer through better global care of the patient, proactively preventing complications, emergency department (ED) visits, and hospitalizations. However, much of the medical home infrastructure that is required to reduced total costs of cancer care comes as an added expense to the provider. As best-of-practice quality standards are being elucidated and refined, we are now at a juncture where payers, providers, policymakers, and other stakeholders should work in concert to expand and implement the OMH framework into the variety of oncology practice environments to better equip them to assimilate into the new payment reform configurations of the future.

Myths and realities in cancer care: another point of view.

Cancer care is advancing, and the cancer community is right to celebrate that progress. Simultaneously, however, the cost of cancer therapy is rising along with all medical costs. In a matter of just a few years, the cost of health coverage is projected to reach heights that are simply unsustainable for most American families, overshadowing every other daily expense. Such an overwhelming burden will continue to undermine the progress made in developing new, more effective treatment and care for cancer patients. There cannot be a celebration of discoveries if there is no way to pay for them. It is from that perspective that I react and respond here to the commentary of Dana Goldman and Tomas Philipson, who debunk five myths in cancer care. I concur with the authors' assessment of the value and impact of progress in cancer care. However, I also argue that researchers and policy makers must pay more attention to the impact of cost on patients' adherence and experience and the speed with which new treatment and care are being developed.

Changing physician incentives for affordable, quality cancer care: results of an episode payment model.

PURPOSE: This study tested the combination of an episode payment coupled with actionable use and quality data as an incentive to improve quality and reduce costs. METHODS: Medical oncologists were paid a single fee, in lieu of any drug margin, to treat their patients. Chemotherapy medications were reimbursed at the average sales price, a proxy for actual cost. RESULTS: Five volunteer medical groups were compared with a large national payer registry of fee-for-service patients with cancer to examine the difference in cost before and after the initiation of the payment change. Between October 2009 and December 2012, the five groups treated 810 patients with breast, colon, and lung cancer using the episode payments. The registry-predicted fee-for-service cost of the episodes cohort was $98,121,388, but the actual cost was $64,760,116. The predicted cost of chemotherapy drugs was $7,519,504, but the actual cost was $20,979,417. There was no difference between the groups on multiple quality measures. CONCLUSION: Modifying the current fee-for-service payment system for cancer therapy with feedback data and financial incentives that reward outcomes and cost efficiency resulted in a significant total cost reduction. Eliminating existing financial chemotherapy drug incentives paradoxically increased the use of chemotherapy.

Roundtable--the changing oncology landscape: evolution or revolution?

Complex challenges face all players in the oncology landscape, from health care policy leaders and third-party payers, to practicing physicians and nurses, to patients and their families. In these unsteady economic times, possible answers proposed by some may represent part of the problem to others. A distinguished panel assembled at the NCCN 18th Annual Conference: Advancing the Standard of Cancer Care to explore the changing oncology landscape. This article is the synopsis of that discussion, with panelists shedding light on such issues as the astronomic cost of medical care, the need for clinicians to think outside the formulary, and the therapeutic decision-making process in the new world of "big data."

Practice-Changing Strategies to Deliver Affordable, High-Quality Cancer Care: Summary of an Institute of Medicine Workshop.

The authors summarize presentations and discussion from the Delivering Affordable Cancer Care in the 21st Century workshop and focus on proposed strategies to improve the affordability of cancer care while maintaining or improving the quality of care.