About 40 percent of the U.S. population will develop cancer. And almost everyone will be affected many times over by their relationship to someone with cancer — as family members, caregivers, friends or co-workers. Further, rising costs around cancer impact us all — driving up the cost for employers to provide health benefits, and the total cost of health care that is spread across the system through higher premiums, cost sharing and taxes.
In short, we’re all stakeholders in the fight against cancer. But, unfortunately, different stakeholders across the health care system haven’t always been aligned around the same goals.
The Highmark Cancer Collaborative is designed to overcome that challenge.
“Our mission is nothing less than to revolutionize how cancer treatment decisions are made, how cancer care is delivered and how cancer care is paid for,” said Dr. Virginia Calega, Highmark’s vice president of strategic clinical solutions, at a press conference in 2016.
When the collaborative launched in western Pennsylvania, it brought together Highmark’s insurance expertise with the medical and research excellence of the Allegheny Health Network (AHN) and the Johns Hopkins Kimmel Cancer Center. A second collaborative launched in June 2016 involving PinnacleHealth, and Highmark is meeting with other forward-thinking providers about additional partnerships in other regions.
To improve safety, quality and outcomes for patients while reducing overall costs, the core elements of each collaborative include:
Don Bertschman (DB): The Highmark Cancer Collaborative brings together clinicians from both sides — insurance coverage and care. You started as a practicing doctor — could you talk about your journey from practicing physician to health plan VP?
Dr. Virginia Calega (VC): Sure — I am a board-certified internist and geriatrician, and I worked with patients for 13 years at different practices. At one large, multispecialty practice in central Pennsylvania, I had a series of leadership roles and ultimately became president. In these leadership roles, I really enjoyed the ability to make a difference on a larger scale. When the founding partners dissolved the practice, I decided to get my MBA, and then I joined Highmark.
In clinical practice, you’re taking care of that one patient in front of you. But on the insurance side, you can impact a whole lot of people through population health management and by helping to design programs and products. I think that’s the journey a lot of us have done — enjoying clinical practice, but wanting to make a bigger difference.
DB: Given that you’ve been in different parts of the health care system, what insights do you have about the historical obstacles to collaboration that an initiative like the Highmark Cancer Collaborative is trying to overcome?
VC: One thing that strikes me about different parts of the system is that everyone uses the same words, but they have different meanings. You can be having a conversation and if you’re not attuned to the differences in what certain words mean to them compared to you, you end up in different places. So, in the silos in the system that have not worked well together — even the language isn’t aligned.
And incentives are not aligned. Somebody running a hospital may have an incentive, because they have payroll to make, to increase the number of tests they do — even though some tests might not be necessary. On the insurance side, we work with the employer groups — who are paying for health insurance — and they want to eliminate the extra cost of unnecessary tests. Clinicians are thinking about what’s best for the patient — but some of them are also impacted by business concerns. So the incentives between all parties haven’t been aligned.
DB: Which feeds back to the language — different incentives will impact how language is used and what it means. So, what is the incentive to overcome these nonaligned incentives?
VC: The cost of health care has become a true crisis in this country. The Affordable Care Act has increased access to coverage, but it does little to address the cost of care. Pharmaceutical costs continue to skyrocket — in cancer alone, costs are rising 17 percent per year. The median cost of new cancer drugs coming to market is nearly $10,000 per month. So — the Cancer Collaborative is about forward-thinking stakeholders recognizing that this simply isn’t sustainable. It’s everyone observing that the current system is broken, and then committing to change the system and incentives to align around why we’re all here — that patient.
DB: When we interviewed Dr. Parda about the Highmark Cancer Collaborative, he pointed out that focusing on the patient isn’t limited to treatment — we have to look out for a patient financially, too. There’s that statistic about 1 in 3 patients who go through cancer treatment declaring bankruptcy.
VC: Both the clinical health and the financial health of the patient are critically important, and they should be considered together. And it’s not just about the individual patient — it’s also about their family and caregivers.
The unique opportunity here is looking at clinical aspects of cancer to make sure that the patient gets the right treatment at the right time — neither too much nor too little. Unwarranted variations in the delivery of care have both health and financial consequences.
DB: How does the Highmark Cancer Collaborative address these variations?
VC: One way is by creating smarter payment mechanisms. For example, there are different lengths of radiation treatment for a woman with breast cancer — a three-week course and a six-week course. There has been data out for about a decade that many women will do just as well with the three-week course as they will with the six-week course — and obviously with less toxicity. The specialty society for radiation oncology, ASTRO, has recommended that women should receive the three-week course of treatment where appropriate. The good news is that AHN is already doing that.
However, on the provider side, there can be a financial disincentive to deliver a three-week course rather than a six-week course. With our bundled payment model we work closely with the provider to agree on one payment amount upfront — so that the provider knows for any woman being treated for breast cancer with radiation, this is what you’ll get paid. In return, we remove prior authorization — you can treat a specific patient with the three-week or six-week course, because we’ve both agreed to remove the financial incentive that might lead to more six-week treatments than is necessary. This also reduces administrative hassles for the provider, and gives them predictable accounts receivable.
DB: That sounds like a win for everyone.
VC: It comes back to making sure patients get the right drug and right dosage for their specific cancer and stage of cancer. Another way we’re partnering with providers through the Highmark Cancer Collaborative is to give them a decision-support software tool, powered by the National Comprehensive Cancer Network (NCCN) guidelines. They use this tool — McKesson’s Clear Value Plus (see sidebar) — as they are seeing the patient. For a given patient, demographic and stage of cancer, the tool serves up the best treatment option based on the evidence to date.
The system then captures the physician’s decision about treatment — including a text box that allows doctors to explain why they may have deviated from the pathways. So, oncologists, administrators, insurers — we’re all using the same information and we have access to it on demand, in real time.
One way we’re using the tool is to combine it with a reimbursement model where we’ll remove prior authorizations on 32 high-cost chemotherapy drugs if physicians are in concordance with pathways — because of the tool, we can track this in a transparent way.
DB: Prior authorization is something many patients have a hard time with — they don’t always understand why the insurance company makes their doctor go through that extra step.
VC: You can think of prior authorization as a blunt tool to ensure the quality, safety and appropriateness of the care being delivered to patients. In a prior authorization, you’re essentially saying Mrs. Smith is this demographic, she has this stage of cancer, this is the recommended first-line treatment, and so that’s what is covered unless the doctor explains to us why it should be something else. Clear Value Plus does the same thing in a more refined, elegant way.
Really good clinicians cannot imagine that anyone would ever order a medication that may not be appropriate for a person. But on the insurance side, you see these very wide variations in treatment, and you begin to understand why prior authorization exists.
Also — cancer treatment is very complex. Trying to stay up to date while you’re seeing all your patients is very difficult given the explosion of new medications and care techniques. The tool narrows that information down for the doctor — and it’s customized to the patient’s demographic and clinical data.
DB: The Highmark Cancer Collaborative existed before this year’s public launch and promotion — and it’s truly a long-term, ongoing commitment. What are you excited about in terms of its bigger picture and future?
VC: I describe the Cancer Collaborative as an umbrella — under which we have a number of initiatives. Our most mature initiatives are around medical oncology pathways, including the new reimbursement model and the decision-support tool. We’re working with McKesson to add cost information to the tool. Patients with cancer are coming to physicians more and more to discuss cost, but physicians haven’t had that information. The tool will soon be able to load the cost of a specific regimen — so the physician and patient can look at their choices and make an informed decision.
On the payment side, we are working toward development of a total bundled payment — so, for a patient with a specific cancer at a specific stage, we have an agreement with a provider on the amount they will be reimbursed for all the services for that patient during a certain time frame. So the clinician can focus on what the patient needs and we can remove some of those extra administrative processes because we have an agreement that covers all the care that patient needs.
We’re also working on initiatives to bend the cost curve with pharmaceuticals. The biggest driver in cancer costs is new drugs coming to the market — it’s not unusual for a treatment to cost $100,000, and in some circumstances, only give a patient an extra two weeks of life. There is a lot of conversation in cancer now about value-based pricing for drugs. Many other countries use the quality-adjusted life-year (QALY) system to factor the impact to the patient into what will be paid and what will be on a formulary.
We’ve also worked on how we design health insurance products for patients with cancer. Some products already include a second opinion consultation through Hopkins for rare and complex cancers with no cost sharing for members. In rare and complex cancers like pancreatic cancer or sarcomas, about 25 percent of the time, an initial diagnosis or treatment plan could change — so access to a second opinion matters. That’s an example of thinking about ways that product design can help patients.
DB: The marketing approach behind the Highmark Cancer Collaborative right now is focused on employers. Why are employers a key player?
VC: One: Employers are actually paying for the care. They’re a key stakeholder in wanting to bend that cost curve and looking for innovative ways to manage costs. Two: Employers have the ability to reach a lot of people all at once. If we engage with the employers, and they buy into this, then they can have the conversation with their employees.
Employers are also genuinely concerned and want to make sure that their employees are getting the right care at the right time with the right clinicians. With the tools that we have now, we’re able to say here’s a provider doing really good work, because we have objective evidence of that. Employer groups have also entered the conversation about pharmaceutical costs. As we try new strategies in the market, they can help us by lending their weight with pharmaceutical companies and reinforcing that the cost increases are not sustainable.
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