The Lynx Group

Insurance Payers and the Cancer Care Value Perspectives

Conference Correspondent

During this session, a distinguished panel, moderated by Mike Kolodziej, MD, Vice President, Chief Innovation Officer at 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 the accessibility of high-quality oncology drugs in today’s healthcare system.

Surya Singh, MD, Former Vice President, Medical Management at CVS Health, discussed strategies that he believes will work to 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. 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.”

Robert McDonough, MD, Senior Medical Director, Clinical Policy Research & Development at 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,” he said.

Bill Winkenwerder, MD, Chairman, CitiusTech, Inc, Former Chief Executive Officer at Highmark Health, predicted that, in the near future, the government is likely to play a bigger role, 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. 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 at 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 on patient outcomes. He also said 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 cited governmental 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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