WellPoint's cancer care program sets standard for oncology management

Evidence-based medicine should guide care. It’s a simple premise that will have profound effects on managed care and the delivery of healthcare in the next few years, says Wellpoint’s President and CEO Joseph R. Swedish in an exclusive interview with Managed Healthcare Executive.

Consider that one in three people treated with chemotherapy do not receive a treatment plan consistent with current medical evidence.

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This fact, coupled with the predicted rise in cancer cases, rapid acceleration of new cancer therapies in the United States and escalating costs associated with drugs and treatment, all signal a need for a system that recognizes and effectively manages costs while delivering evidence-based outcomes.

It’s why WellPoint unveiled a new Cancer Care Quality Program that targets an oncology sector experiencing rapid development and advancement.

It’s novel, scalable and the company believes it will be effective in treating cancer patients based on scientific evidence to achieve best outcomes.

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Swedish calls it the new story of managed care. The old story is that it will help dampen exploding costs.

“There are so many technological advancements, not just in the pharma space but as it relates to diagnostics and other areas,” Swedish says. “The consumer is being put in an ever-increasing position of risk, and an ever-increasing opportunity for great success. That is where we believe we have a very significant responsibility to support the decision-making choices that our members must make in this new world.”

While the drug spend in the United States represents just 9% of total healthcare expenditures, specialty pharmaceuticals hover around 25%,  and “that could escalate to 40% of the pharma spend easily,” Swedish says.

WellPoint’s new program attempts to align incentives for oncologists based on recommending treatment options that have scientific evidence to support their effectiveness. The insurer spends about $5.5 billion on cancer care. By incentivizing oncologists for choosing evidence-based options to guide decisions, the company believes it can save 3% to 4%, or about $220 million a year.

The program was rolled out to six states in July (Indiana, Kentucky, Missouri, Ohio, Wisconsin and Georgia), and will be followed by California, Colorado and Nevada by the end of the year. New York, Connecticut, Maine, New Hampshire and Virginia will implement by early- to mid-2015, and the program will be active in all 50 states by 2016.

Joseph R. Swedish, CEO WellPoint

A new pathway

WellPoint developed this program with AIM Specialty Health and identified cancer treatment pathways based on medical evidence, peer-reviewed published literature, consensus guidelines and the company’s clinical policies. 

A pathway is more specific than a clinical guideline in that it identifies treatments based on clinical benefits, favorable side-effect profiles and cost. WellPoint says its pathways are developed using national clinical guidelines and are reviewed by 10 geographically diverse oncologists who are actively treating patients and work in academic and community oncology groups.

SwedishSix of those members are on faculty or affiliated with National Cancer Institute designated cancer centers, seven are affiliated with Blue Centers of Distinction, four are in community practice settings and six have served on national committees for organizations such as National Quality Forum, American Society of Clinical Oncology and Institute of Medicine to improve cancer care.

So far, the program identified 24 pathways for breast cancer, 16 for colorectal cancer and 22 for lung cancer. The plan will add myeloma, lymphoma, ovarian and pancreas cancer pathways this year and next.

If a participating oncologist chooses one of WellPoint’s pathways, the practice will receive a $350 one-time fee at the start of treatment planning and care coordination, and the practice will receive $350 a month per-patient while the patient is active in therapy and on a pathway.

If an oncologist chooses not to pursue the pathway, they simply won’t receive the enhanced reimbursement, but would be paid according to the terms of the member’s health plan.

AIM will administer the program through www.cancercarequalityprogram.com. The company has also set up a provider portal to help manage registration and educate practices on preparation and receiving enhanced reimbursements. 

Ultimately, the program helps synchronize clinical guidelines with health plan medical policy to better manage cancer cases that are poised for an increase in incidence and prevalence as the U.S. population continues to age and as new technologies emerge to help identify cancer earlier and improve survival rates.

Key cost drivers for oncology

While costs of caring for cancer patients topped $124 billion in 2010, just a 2% increase in costs during the initial diagnosis/care phase and last year of life would increase this country’s oncology-related care costs to $174 billion in 2020. A 5% cost increase in those two phases would send the total cancer care spend to $206 billion in the next 6 years. 

And as the U.S. population continues to age, the numbers of people diagnosed with cancer will climb, steadily. In fact, cancer prevalence rates are set to increase by 31% for some 18 million people in the United States, according to the National Cancer Institute. Survival rates are also believed to increase by 30% by 2020.

“We are reflecting and trying to moderate the total cost of care that members are exposed to,” Swedish says. “Given their exposure to escalating costs, we have to be absolutely sure they are being used according to evidence-based practice as opposed to the unfettered use of these technological advancements.

“We want to make certain that our long-term strategic engagement in the market helps us manage to a new future, not just relative to where we are today or where we have been in the past,” Swedish adds. “Members are looking for new value and how they access the system, and they want to make certain the value comes to them through technologies that work.”

The program’s goal, according to WellPoint, is becoming the industry standard for “measuring and paying for evidence-based oncology treatment planning and care.” The insurer also hopes to potentially improve outcomes, decrease variation in care, lower toxicity and reduce hospitalizations associated with treatments.

“The pursuit of quality of life is very prevalent and demanding, as it should be,” Swedish says. “We need to do our part to make those services available but at a cost that maps perfectly to the value of the service that is delivered. We have a real opportunity to impact and bend that cost curve as a nation.” 

Daniel R. Verdon is an Advanstar contributor.