Oncology care marketing increasing in the U.S. marketplace. However, continuing benefit coverage planning for 2017 are also topics that are receiving increasing attention—to include cancer care.
Just as the new oncology product pipeline is providing new options or treatments for a wide variety of cancers, market stakeholders are continuing to adjust their daily practices around providing care, decision-making on therapies or product coverage in 2016 due to the continuing impacts of ACA on commercial markets too.
Geographic as well as plan specific “tweaks” continue to pop-up while nearly all plans are actively engaged in 2017 market planning for health benefit coverages that will likely result in more or different access changes for various stakeholders.
Stakeholders are increasingly reviewing four key oncology alternative payment models:
- Clinical pathways are based on National Comprehensive Cancer Network (NCCN) guidelines, and considered by many as the first step toward more comprehensive payment and delivery reform in oncology. Texas Oncology is actively promoting their approach for optimal outcomes and Cancer Medical Home. Paradoxically, this does work and can provide value to employers, but not necessarily for 3rd party payers.
- The Patient-Centered Oncology Medical Home includes a fixed PMPM fee for clinicians that meet a specific set of capabilities and quality standards in their practices.
- The Oncology Accountable Care Organizations (ACOs) framework introduces a shared saving model based on overall patient costs and quality of care in addition to FFS reimbursement.
- Bundled Payments is a combined payment for a package of clinically related services in a case or episode of care, including multiple services from a particular provider or the services of multiple providers. United Health Care, while decreasing ACA plans, is discussing their bundled payments model driven by Dr. Lee Newcomer with health plan focused cost savings using comparative analyses and reference based information to drive cost down.
Other efforts include:
- Reference based pricing – building off of CMS/Medicare efforts to create market norms for care costs by MSA.
- PBMs are out promoting their value based formulary strategy which look to continue driving therapeutic substitution or generic opportunities whenever possible while addressing transparency on contracting and rebates.
Commercial self-funded plan sponsors are becoming more engaged and looking more closely at cancer care and immunology as just two recent examples. Contracting for health services using alternative payment models is increasing, but overall remains low for drug contracting alone among employers of all sizes.
Overall as a commentary, this emerging effort in the commercial market is moving trend down more than up. For specialty and biologic drugs much the same – the manufacturer still controls drug cost and 3rd parties working off of those numbers play the game of savings. Without a true structural change in health care financing, i.e. insurance innovation like seen with Endeavor Plus, year over year trends will continue up and unsustainable for commercial self-funded plans.
AMI continues to follow weekly managed market changes in pharmacy and medical benefits, while also looking into the near future that is quickly shaping up to be quite disruptive in 2017-2018 compared to prior years. www.accessmarketintell.com