The Lynx Group

Getting to Value in Cancer Care: The Time to Have That Conversation Is Now

June 2014, Vol 5, No 5

Chicago, IL—The question of value in oncology continues to pose challenges for oncologists and payers alike, as the costs of therapy continue to rise and health plans are wrestling with the need to design insurance coverage that promotes value. The American Society of Clinical Oncology (ASCO) is encouraging oncologists to discuss value and costs with their patients, but oncologists often find themselves unwilling or unable to do so. Nevertheless, all agree that discussing value is inevitable and must begin to happen, but how to get there remains a challenge for all stakeholders, including health insurance plans and oncologists, suggested Lee N. Newcomer, MD, Senior Vice President of Oncology, UnitedHealthcare, at the 2014 ASCO annual meeting during a session titled “Can We Find Common Ground? Stakeholder Perspectives on Value in Cancer Care.”

Value-Based Insurance
“We have to start having discussions about value, and we are going to have to say that there are certain things that should not be covered,” said Dr Newcomer.

The idea behind copayment or coinsurance “is for the patient to pause and ask, ‘Is this worth the money?’ Copays were never intended to be large enough to keep people from getting important, high-value care, but to keep them from selecting lower-value care, if they have to pay the first $50 or a percentage,” Dr Newcomer said.

He suggests that it is time to shift the structure of insurance copayment in oncology so that patients will pay less for high-value drugs and services and more for drugs and services with low value, to facilitate value-based care. “A high-value service might have a complete coverage, with no participation from the patient whatsoever, and low-value would have much higher participation, having the patient pay a third, a half, or even all of it, if it didn’t have true value,” Dr Newcomer emphasized.

“It will be difficult for consumers to understand this for every service they will receive,” he said. Consumers are largely unclear about their benefits. “In a value-based program, we are asking consumers to take on an increasingly large amount of information that may be even harder to digest,” said Dr Newcomer. It could be overwhelming for “a consumer to sort out a 2-month versus 4-month survival benefit, or grade 5 versus grade 4 toxicities,” he added. “Trying to make this concept easily accessible to consumers, helping them find out the value of a given treatment, is a daunting task and has been a major barrier to getting value based insurance in place.”

The Challenge for Payers
Equally overwhelming for payers will be sorting out the different diagnoses and treatment regimens and figuring out how to assign coinsurance values to each treatment and service.

“Where do we draw the line, where we say one thing should be free, and another should have 30% participation?” Dr Newcomer asked. “No matter where we draw the line, someone will be unhappy.”

In addition, who should decide, and how will it be determined, what will be the patient participation in the care provided? These challenges are daunting, but they have to be addressed. “It’s important for us as payers to have this done externally, because we will always be perceived as making these decisions from a financial basis only,” said Dr Newcomer.

Once these parameters are determined, he said, it will be easier for payers to set prices. The more generous the benefit, the higher the overall price of the premium will be, and this should help consumers to understand the concept of value.

“The thing that’s the hardest is simply not paying for anything at all,” Dr Newcomer said. ASCO has already recommended that patients with metastatic breast cancer receive only single-agent chemotherapy (except under certain circumstances), but if insurance plans restrict payment to only one drug, it would result in strong public reaction in the United States, he predicted.

“The immediate perception of value-based insurance is that it’s simply being done to save money,” Dr Newcomer suggested. “Putting these programs in place will have to be a gradual process, accompanied by education.”

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