The Lynx Group

Payers' Perspectives on Value in Cancer Care

December 2019, Vol 10, No 6

New York, NY—At the 2019 AVBCC Summit, a panel of payers, moderated by Mike Kolodziej, MD, Vice President, Chief Innovation Officer, ADVI Health, discussed strategies for improving the delivery of value-based cancer care, along with changes on the horizon as payers and providers strive to maximize access to high-quality oncology drugs.

Surya Singh, MD, former Vice President and Chief Medical Officer, Specialty Pharmacy, CVS Health, discussed strategies that would produce positive changes. “With all their warts, I think we are going to see more bundle-based payments. I think this can work. In several instances, we were able to reduce costs for subsets of patients by having a bundled-payment approach,” he said.

“I also think that we are going to see some sort of reference-based pricing, which is likely to be a hotly debated issue. I believe we are going to see some private payers actually start to implement this for their customers,” Dr Singh added.

Robert McDonough, MD, Senior Medical Director, Clinical Policy Research & Development, Aetna, cited the importance of using established guidelines in the decision-making process. “I know some people criticize the guidelines, but at least they establish some parameters around what is acceptable and what is not,” Dr McDonough said.

Bill Winkenwerder, Jr, MD, Chairman, CitiusTech, and former Chief Executive Officer, Highmark Health, predicted that in the near future, the government would likely play a bigger role in drug pricing, given the current landscape of high-cost oncology drugs.

“It seems to me that we are on a path toward the government taking major action,” Dr Winkenwerder said. “If the industry, which includes pharma, insurers, lawyers, etc, does not come around to something that really feels like it is working, the government is going to act. It is going to be a big issue in the next election.”

Scott Breidbart, MD, MBA, Chief Medical Officer, Affinity Health Plan, cited 3 strategies that have the potential to reduce costs and deliver value-based care.

First, he emphasized the importance of promoting societal change, reminding attendees of how efforts to decrease smoking have led to major improvements in patient outcomes. He added that prior authorization can have a positive impact, acknowledging that it has worked to some extent to reduce the utilization of very expensive therapies. Finally, he noted the government’s imposition of price controls. “I am not saying we are in favor of it, but in the absence of any other change, that’s what’s coming,” he concluded.

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