Building a better oncology managed care program

By now, employers and payers are well aware of the challenges associated with cancer care. While each year brings exciting medical advances that can offer hope to many patients, these breakthroughs — including immunotherapies and gene therapies — are incredibly costly. 

In fact, nearly half of new cancer drugs launched between 2018 and 2023 cost more than $200,000 annually.¹ And given the drugs’ success, many people with cancer are living longer, with some requiring treatment for the rest of their lives.²

As a result of both breakthroughs and longer courses of treatment, annual cancer care expenditures in the U.S. are marching ever higher, projected to hit $246 billion by 2030.³ Already, cancer has exceeded musculoskeletal issues in being the top driver of large companies’ health care costs.⁴

The question of how to deliver high-quality cancer care while bending the cost curve has become an important issue for employers and payers. Like the disease itself, the answer is complex and requires a multifaceted solution that ensures cancer patients receive the right care at the right time. A decade of evidence shows that managed care programs can play a critical role in reducing cancer patients’ complications and overall medical spend.⁵

Here are 3 cornerstones to consider when building a comprehensive managed care oncology program:

More than 2 million Americans are expected to be diagnosed with cancer in 2024, a grim projection that reflects the rising incidence of many common forms of the disease.⁶ As shocking as a cancer diagnosis can be, it’s only the start. Patients are often thrust into a bewildering maze of appointments, tests, discussions and decisions that must be managed in a compressed time frame while they also grapple with the emotional impact of their illness.

As new treatment offerings increase, making choices can be especially difficult. That’s why the best oncology managed care solutions help ensure members have access to appointments and second opinions at cancer Centers of Excellence. These centers offer expanded treatment options and better coordinated care, resulting in fewer complications and higher survival rates.

Managed care programs also embrace oncology pathways to guide decision-making. Pathways are tools created by panels of oncologists and other experts who rely on clinical data and evidence-based guidelines to aid providers in making the best recommendations for a patient’s specific cancer type and stage.

These pathways are based on clinical evidence supporting a treatment’s efficacy and toxicity. If different treatment regimens display comparable efficacy and toxicity, the pathways then take into account drug costs.

Advanced pathways also consider data from health care claims regarding the duration of treatment and the rate of hospitalizations during treatment, along with the total cost of care. The multidisciplinary experts responsible for pathways continually refine their work as well. By regularly coming together to review emerging trends and current literature, experts ensure that plans offer patients pathways that are based on the latest in evidence-based medicine.

By standing alongside patients during the difficult early days after a cancer diagnosis, the right managed care plan can enhance quality and value in oncology care. Providing access to clinically proven best-in-class care and treatment pathways can help patients cut through the morass of medical information to determine the right treatment plan that offers the best outcomes and value.

The need for support extends far beyond initial oncology treatment decisions. That’s why the best managed care programs also offer patients experienced advocates who follow them throughout the course of their illness.

Specialized oncology nurses should be available to meet one-on-one with patients, helping them navigate treatment while also learning about each individual’s support system, social context, comorbidities and other factors that may impact their treatment or ability to receive care. These nurses help patients coordinate care, prevent and manage symptoms and side effects, and connect with their doctors at every stage of treatment — all via phone, text and digital channels.

Nurses can also help patients and their families make difficult choices if the cancer doesn’t respond to treatment. Research has shown that cancer treatment for people nearing death has grown increasingly aggressive over time, despite evidence that less aggressive approaches are associated with better quality of life — and, sometimes, even longer survival times.⁷

By becoming familiar with each patient’s particular needs, these nurses can efficiently connect patients with wraparound services that lessen common care barriers and fill care gaps, avoid unnecessary hospitalization, introduce palliative care at the right time, and generally smooth the path through treatment.

To fully maximize outcomes and value in oncology treatment, payers should look for a managed care program that embraces a value-based care (VBC) model backed by a sophisticated system of utilization management metrics and expert payment integrity and claims review processes.

Given mixed results and adoption in VBC programs, a range of VBC models must be made available to providers, including:

• Pay for performance for less sophisticated model
• Risk-sharing opportunities for those with more VBC experience. 

By tracking and rewarding providers’ results, value-based managed care programs can play a critical role in reducing oncology spend while improving patient outcomes. A pay-for-performance model allows providers to earn incentive payments when they adhere to proven cancer pathway regimens, as well as clinical quality targets established by nationally recognized guidelines from the American Society of Clinical Oncology, National Quality Forum and Centers for Medicare & Medicaid Services.

The best VBC programs take a team approach, working with providers to deepen their understanding and utilization of evidence-based recommendations, and learn how to better track and improve their performance against quality metrics. By combining a VBC system with digitally enabled care management, forward-looking managed care plans can enable enhanced care team collaboration and care coordination to improve quality while reducing unnecessary costs.

As the incidence and cost of cancer grows, payers and employers must seek solutions that transform care in ways that drive better outcomes and improved value. 

By placing patients at the center of a new managed care approach, payers can leverage cutting-edge science and high-touch support to deliver the best treatment and avoid the pitfalls of an uncoordinated fee-for-service system — all while offering patients the support they need during a difficult time.