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How Payers Can Continue to Prepare to Cover Patients With COVID-19, Hematologic Malignancies

December 09, 2020

By Edan Stanley 

gary owens, MDGary Owens, MD, president, Gary Owens Associates, explains the unique treatment landscape among patients with both COVID-19 and hematologic malignancies, and explains why payers will need to be aware of this complex and high-cost subgroup and be prepared to manage their care appropriately.

There have been a number of hematologic malignancies in patients with COVID, complicating care even further. How can payers prepare for billing and coverage challenges for COVID treatments in the patient populations experiencing hematologic malignancies? 

Hematologic malignancies are quite common in the US. According to the American Cancer Society there will be more than 60,00 new cases of leukemia, 85,000 cases of lymphoma and 32,000 cases of myeloma in 2020. Most of these cases will occur in older individuals who already at higher risk of COVID-19 complications due to age and non-cancer related comorbidities. Adding to that is the immunocompromise not only of the cancer, but also from the treatments.  Studies from Europe show that these patients have a disproportionately high death rate from COVID-19.  

Payers will need to be aware that for this group of individuals, there are likely to be more and more protracted hospitalizations for some patients.  However, the hospital cost for managing some of these patients may not rise disproportionately due to prospective payment systems already in place. However, many survivors of COVID-19 who have been critically ill in hospitals often have protracted complications such as heart and respiratory conditions that can take months to resolve. That means that some of these patients with hematologic malignancies will not only need their costly cancer therapies but will also need care for their COVID-19 related complications.  

Payers can mostly anticipate that some of these patients will be complex management patients who will need well-coordinated care and care management services from the payer to assure timely and cost-effective care. While payers can’t do anything to impact the number of these cases, they can be prepared to effectively manage the complexities. 

Many patients with cancer and COVID are receiving investigational COVID therapies. Because there is no cost-related data, how do you think this will impact payers? Do you think anything can be done to help estimate costs and prepare for this in the future? 

Paying for COVID therapies will be a continuing issue for payers well into 2021 and beyond. As we gather more data from trials, we are learning what works (e.g. dexamethasone, remdesivir) and what does not work (e.g. hydroxychloroquine). Payers will need to carefully monitor the state of the literature and adjust payment policies and PA criteria accordingly. 

Many treatments of the most severely ill are provided in-patient and covered under prospective payment arrangements or carve-outs for some very expensive therapies.    

Finally, payers will need to gather data on these therapies and their associated costs relatively quickly (likely using completion models that are based on more uncertainty, but shorter timelines) to inform their actuaries of the trends as they project future costs. 

The majority of data that we have on this is from a number of countries other than the US. How can we use this data to help inform treatment decisions within the US?  

I think payers will need to access any sources of data available to get an understanding of the course of the disease and complications, especially for those with hematologic and other malignancies.  As noted before these patients are at higher risk and are more likely to have complications of COVID-19.   Data coming from Spain and Italy show very high mortality rates in these individuals, and high rates of COVID-19 complications. Payers need to be aware of this complex and high-cost subgroup and manage appropriately. The European data also seems to indicate that treatment delays of these patients to potentially avoid COVID-19 complications is also not an option due to the risks and complications of disease progression. 

As a health care professional yourself, how do you or your peers feel about making clinical treatment decisions based upon constantly changing data? 

COVID-19 has taught all of us that we are dealing with many unknowns. The only answer here is that we must work with the data we have, be aware that new data is emerging rapidly and be ready to respond to constant change as we continue to learn more about this disease.

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