 |
| Sample Newsletters | MarketPlace AIS Products & Services |
|
AIS's Health Business Daily
Featured Story March 3, 2010
Health Plan Oncology Strategies Result in First-Year Savings Reprinted from The AIS Report on Blue Cross and Blue Shield Plans*, a hard-hitting independent monthly newsletter on business strategies, products and markets, mergers and alliances, and financing of BC/BS plans. *Not affiliated with the Blue Cross and Blue Shield Association or its member companies. By Steve Davis, Contributing Editor (sdavis@aispub.com) Health plans traditionally have had a hands-off approach to oncology care, opting to let physicians maintain complete control over the process. But with oncology drugs on track to become the biggest driver of specialty drug spend, some Blue Cross and Blue Shield plans are taking a more active approach to oncology management.
CareFirst BlueCross BlueShield contracted with Maryland-based P4 Healthcare to help it work with oncologists to develop clinical pathways that can standardize treatment. Capital BlueCross and Blue Cross Blue Shield of Michigan also have inked deals with P4 to help manage oncology care costs. Meanwhile, Blue Cross Blue Shield of Florida has launched an oncology pharmacotherapy program with combined deductibles between the medical and pharmacy benefits.
When CareFirst reviewed its medical costs a few years ago, “oncology was the low-hanging fruit,” Winston Wong, Pharm.D., associate vice president of pharmacy management at the plan, said at a Jan. 28 AIS audioconference on oncology management. At that time, CareFirst was seeing 25% to 30% increases in oncology costs, he explained.
CareFirst and P4 assembled a group of oncology providers from within the plan’s network to develop and maintain the pathways. “We got immediate buy-in from physicians” by doing this, said Wong.
Rather than setting thresholds that might hamstring physicians’ ability to treat patients, CareFirst allowed oncologists the flexibility to “do a one-off treatment where it’s appropriate,” he explained. The insurer also made certain it provided oncologists with “an efficient means of measuring compliance…with little burden on the office staff,” Wong said.
CareFirst applied clinical pathways to breast, lung and colon cancers and to supportive care for all cancers. The pay-for-quality approach reimburses compliant physicians by a standard fee schedule plus a differential — which is “upwards of about 15%” — and nonparticipating physicians at the standard fee schedule only. “At the worst case, noncompliant physicians are reimbursed like any other provider in the network,” he said. “So there’s no penalty not to participate.”
For breast, lung and colon cancer therapies, compliance during the first year of the program was defined as meeting a 65% treatment compliance threshold. In that year, 90.5% of the participating oncologists were compliant in breast cancer, 72.3% in lung cancer and 90.0% in colon cancer. In the second year of the program, starting August 2009, the threshold for compliance increased to 80%.
Overall, CareFirst has realized 12-month savings of $8.5 million. Asked if the insurer has realized a positive return on investment, Wong said yes. “We didn’t pay P4 $8.5 million,” he explained. For the program’s second year, five more cancer types were added, so “we expect the cost savings to go even higher.”
Fla. Blues Emphasizes Care Management
The Florida Blues plan launched its oncology program, which covers all cancers, in mid-July 2009, Beckie Fenrick, Pharm.D., director of clinical pharmacy programs at BCBSF, said at the AIS audioconference. The care management program has care nurses available to help members navigate their benefits. But BCBSF’s combined deductibles mean that if a member who has not met the deductible goes to a pharmacy and is faced with a $1,000 out-of-pocket payment, “there can be sticker shock.”
When it comes to providers, BCBSF wanted to put in “reasonable management tools,” Fenrick said. The plan imposes maximum-dose limits at times and requires prior authorization on a handful of specialty drugs. On the reimbursement side, BCBSF changed from average wholesale price-based reimbursement to an average sales price mark-up basis. “We worked hard to assure that reimbursement was reasonable,” she said.
Provider education is critical to the program’s success, she contended. And if BCBSF does not approve a therapy, “there will be an oncologist-to-oncologist conversation” to explain the rationale. Fenrick added that the health plan has not seen “significant changes” between provider ratings before the program went into effect versus after its implementation. Before the program’s launch, BCBSF’s medical oncology costs were increasing at a 30% annual trend rate. The rate is now about half of that, Fenrick said. |
| ||||||||
