Las Vegas—Cancer is the most costly area of care, with costs increasing at 2 to 3 times the rate of other medical conditions. And while the mortality rates associated with cancer are decreasing, the decline is slower than other conditions, such as heart disease.
During a session at the NAMCP forum, Michael Kolodziej, MD, FACP, national medical director, oncology solutions, Aetna, discussed how health plans can improve oncology care, particularly presenting perspectives from Aetna.
Dr. Kolodziej noted Aetna’s top cost drivers in cancer care include medical prescriptions at $1.5 billion (30.8% of the cost), inpatient care at $1.1 billion (23.3%), radiology at $1.1 billion (22.4%), and specialist care at $483 million (9.4%).
In addition, the healthcare system produces $750 billion in waste annually, which amounts to approximately 30% in health spending. Examples of waste include:
• Unnecessary services (27%)
• Excess administration costs (25%)
• Inefficient care delivery (17%)
• Inflated prices (14%)
• Fraud (10%)
• Prevention failures (7%)
Healthcare premiums are also growing at 3 times the rate of inflation and wages, leaving consumers paying for nearly half of the increase in medical premiums. In response to growing costs of oncology care, solutions that have arisen include less being covered; managing more through prior authorization; shifting responsibility to the member via copayment, value-based insurance, and reference pricing; pay-for-performance incentives; and shifting the risk through accountable care organizations.
Dr. Kolodziej said increased adherence to evidence-based guidelines lowers costs without negatively impacting treatment efficacy. He presented a study demonstrating that adherence exceeded their expectations. Baseline adherence data on >200 patients was pulled from chart reviews of 5 practices for the 6 months prior to the start of the pilot study. A total of 103 participants were compared, and the absolute increase was 25%, with a 43% relative risk.
In the study, for colorectal cancer, adherence rates remained the same at 79% from baseline to the study period. For breast cancer, adherence to evidence-based medicine increased from 69% at baseline to 91%. For lung cancer, adherence increased from 79% at baseline to 89%. And, for lymphoma, adherence increased from 61% at baseline to 100%.
Dr. Kolodziej also shared an Aetna oncology pilot study that included 156 physicians in 7 locations. By enabling physicians with clinical decision support tools, care can be improved, costs can be reduced, and quality can be maintained, he noted. The pilot study saw a net savings of $393,599 due to reduced emergency room (ER) visits, inpatient hospital stays, and spending on certain drugs. The pilot program also resulted in a 28% decrease in treatment variability and an 11% increase in regimen of generic-only utilization.
Since 2005, ER visits per chemotherapy patient have decreased 70%, and hospital admissions per chemotherapy patient have decreased 50% since 2007. Dr. Kolodziej noted that quality reporting on ER visits, hospitalization rates, and chemotherapy costs are important.
Dr. Kolodziej then highlighted 5 typical challenges that oncology practices face: (1) the average number of physicians is 5; (2) approximately 60% are using an emergency medical record; (3) staffing margins are very lean; (4) unable to develop and implement standardized scripting organically; and (5) unable to measure and report impact of the program.
He presented the Aetna Compassionate Care program, which provides additional support to members with advanced illness and gives their families/caregivers access optimal care. The program includes nurse case managers who are trained to:
• Assess and manage members’ care in a culturally sensitive manner
• Identify resources to make members as comfortable as possible, addressing pain and other symptoms
• Help coordinate medical care, benefits, and community-based services
• Inform the member about treatment options, continuity of care, and advanced care planning
• Provide personal support
• Consult and coordinate with the members’ treating physicians and staff
As community oncologists are migrating to hospital systems, costs are increasing, said Dr. Kolodziej. According to 2010 data presented, 172 oncology clinics across the United States had closed, 323 practices were struggling financially, 44 practices were sending all patients elsewhere for treatment, 224 practices were acquired by a hospital, and 102 practices had merged or been acquired. Therefore, hospital providers need a new business model for financially stable oncology care. He presented a 5-step oncology care delivery process: (1) modeling; (2) clinical analytics; (3) value creation plan; (4) delivery; and (5) ongoing collaboration.
“Oncology medical home practices are excellent partners for accountable care organizations [(ACOs)],” said Dr. Kolodziej. He explained the Aetna oncology medical home practice process. Hospitals contract with Aetna to provide medical home solutions to its network oncologists. The tool then enables the ACO to benchmark community practices. The ACO then engages oncology practices in shared savings arrangements or episode-based reimbursement.
The benefits to bundling oncology care include care occurs in a discrete episode, there is variability that does not impact quality, and bundling in the form of episode payments has worked for other medical conditions.—Kerri Fitzgerald