Post-ASCO Survey: Oncologists’ and Payers’ Treatment and Coverage Decisions

Caroline Helwick

August 2011, Vol 2, No 5 - Reimbursement


An analysis of payer and provider responses to key clinical information presented at the ASCO 2011 annual meeting offers a glimpse of the oncology landscape shared by oncologists and health plans.

The research was conducted by Xcenda (AmerisourceBergen Consulting Services), a specialty pharmaceutical research and consulting firm. The full study, led by Loreen M. Brown, MSW, Vice President of Xcenda’s Access and Reimbursement Consultancy, was published online in the Oncology Business Review (www.oncbiz.com; July 2011).

“We wanted to draw connections between the new data presented at ASCO and the payer–provider responses,” said Ms Brown, “to determine if payers and providers in the oncology space are congruent or divergent in their thinking. ASCO is a great time to see what oncologists are planning to do with new data and to see if payers are paying attention.”

Ms Brown and her team conducted an online survey of oncologists and health plan decision makers. The survey included questions about the awareness of clinical trials and the changing attitudes and behaviors of oncologists, as well as views regarding incipient changes to coverage and treatment policies.

“By offering real-world insight into what is important to 2 key stakeholders, our research provides an overview of how emerging oncology data influence treatment and coverage decisions, especially in the present context of skyrocketing healthcare costs,” Ms Brown told Value-Based Cancer Care.

Which Novel Agents Captured Attention?

Oncologists reported high awareness of clinical trial data for a number of established biologics and several novel agents in late-stage development. Not surprising, considering the amount of publicity of recent findings, ipilimumab garnered the most notice (88%). Also receiving high attention were new data on bevacizumab (82%), erlotinib (75%), abiraterone acetate (75%), panitumumab (72%), and cetuximab (68%).

Of note, despite the poly(ADPribose) polymerase inhibitor’s high profile and the anxiously awaited phase 3 data, iniparib was acknowledged by only 62% of providers. And only 55% of responders had heard the vemurafenib data for melanoma, which were presented in the plenary session along with the ipilimumab study.

More oncologists were unaware than aware of findings related to the investigational drugs ponatinib, ruxolitinib, tivantinib, and MetMab.

Increasing Use of Diagnostic Testing

Not surprising, given the wealth of data supporting targeted use of many biologics, tissue-based molecular diagnostic testing for genetic factors such as epidermal growth factor receptor expression and KRAS mutations is going to increase. More testing to guide treatment decisions is expected for lung cancer, melanoma, and colo – rectal cancer.

Two thirds (67.5%) of oncologists intend to increase their present use of diagnostic testing based on what they heard at ASCO. Another 30% predict their use will remain stable, and only 2.5% said they expected to use less diagnostic testing.

Eighty percent of oncologists and payer survey respondents plan on targeting surveillance testing or imaging to situations in which benefit has been shown. “Anecdotally, from our conversations, we know that physicians and payers are all for diagnostic testing, which could lead to cost-savings by treating the right patient with the right drug at the right time,” Ms Brown said. “But the issue at this time is that the validity of the testing remains undetermined. Some tests, such as for HER2 expression, work beautifully, whereas others are still being evaluated. Payers and providers are on the same track—as long as the tests are reliable.”

Actionable Reimbursement Strategies

Although treatment guidelines aim at optimizing patient care while keeping it cost-effective, approximately 66% of oncologists do not always adhere to guidelines in their plans or practices as a means for reimbursement. Lung, breast, and colorectal cancers are the tumors for which guidelines are most likely to be adhered to and for which reimbursements are most likely to be based.

“Over the next year, however, based on data presented at ASCO, new disease states may be added to predetermined treatment contracts. More than 20% of providers are considering the addition of melanoma,” she noted, “and payers are considering the addition of multiple myeloma, chronic myeloid leukemia, and melanoma guidelines to this type of contracting arrangement.”

Another reimbursement issue is the policy discrepancy between infused and oral oncolytics. Here, the survey revealed that many payers are un – aware of cost issues related to oral drugs. “There is a striking distinction,” Ms Brown said. Only 50% of payers seem aware of the differences between these types of agents (eg, the higher copays for patients).

Aligning Interests Regarding Costs

A recent article in the New England Journal of Medicine (Smith TJ, et al. N Engl J Med. 2011;364:2060-2065) suggested that oncologists can help reduce the cost of cancer care through specific behaviors and actions. This included reducing surveillance testing or imaging, using sequential mono – therapy instead of combination therapy, limiting chemotherapy to patients with good performance status, replacing the routine use of growth factors with chemotherapy dose reductions in metastatic solid tumors, enrolling patients on clinical trials when chance of success is minimal, and integrating palliative care.

The New England Journal of Medicine authors also wanted oncologists to recognize that costs of care are driven by what they do and do not do and to have more realistic expectations,” Ms Brown said.

Additional suggestions were to realign compensation for cognitive services to utilize cost-effectiveness analysis and to accept greater limits on care. The survey included questions about the New England Journal of Medicine article’s suggestions for cost containment. The responses showed that providers and payers generally agreed that certain evidence-based behaviors and attitudes on the part of oncologists would lower overall costs to the healthcare system (Figures 1 and 2). For example, almost all of both stakeholder groups believe that palliative care should be integrated into oncology treatment.

However, “there were nuances to the different payer perspectives,” according to Ms Brown.

For example, >50% of the payers argued that the routine use of growth factors could be replaced by reductions in chemotherapy dose in patients with metastatic solid tumors. Only 30% of providers, however, were accepting of this strategy. Also, oncologists desired reimbursement of cognitive services, which shows “a disconnect” between “what providers seek and what payers compensate,” she said. “Time spent talking to patients about the treatment plan, side effects, end-of-life care, and so forth is time that the oncologist is not paid for.”

Oncologists are also less agreeable than providers to reducing chemotherapy among patients who do not respond to 3 consecutive regimens (Figures 3 and 4). “The responses indicate that payers work more keenly toward constraining cancer costs,” Ms Brown said.

However, 85% of providers and payers strongly agree that physicians’ and patients’ expectations must be reset to be more realistic. To align payers’ interest in cost containmentwith oncologists’ perceptions of quality care, increased collaboration and improved communication within the payer–provider relationship are required.

How might this be done? “Payers and providers first need to understand that they are on the same side,” Ms Brown said. “Until recently, there has been an ‘us versus them’mentality. The contract negotiations were mostly about how much physicians were paid for the drugs they used. Moving into the new healthcare reform world, with episode payments, bundling, and payment for quality, there is a broader picture of reimbursement. It is not just about individual services. And both groups are amenable to that. The question is how to come upwith a systemof reimbursement that is episodic and that meets the needs of both parties.”