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Anthem’s Clinical Pathways Demonstrate Value: The Payer Perspective

August 2015 Vol 8, Special Issue: Payers' Perspectives in Oncology

At the special session on value during ASCO 2015, Jennifer Malin, MD, PhD, Staff Vice President for Clinical Strategy, Anthem, Thousand Oaks, CA, presented the payer perspective on value in cancer care. The role of the payer, Dr Malin said, is to balance different stakeholders’ values and needs at various time points.

“It’s important to think about value from the position of all stakeholders,” Dr Malin said. “We need to have quality and affordable cancer care, reimbursement needs to be aligned for providers so that they can achieve desired outcome, and we need to encourage clinically meaningful therapeutic innovations. I think that by highlighting those therapies that are the most effective and that bring the greatest value to patients, we also help to achieve that goal.”

Part of the payer’s balancing act involves thinking about future patients, not just those facing life-threatening illness now, and that means considering the “overall total cost of care,” including next year’s insurance premiums and out-of-pocket costs.

“Patients are making decisions way before they ever get diagnosed with cancer that impact their out-of-pocket costs, and what they choose,” Dr Malin said. “If they pick a high-deductible plan because they can only afford low premiums, then that leaves them in a situation of facing much higher out-of-pocket costs.”

Huge Variations in Drug Cost

One of the keys to understanding value lies in negotiating among clinical benefit, toxicity, and cost. Presenting the 6 treatment options for non–small-cell lung cancer as an example, Dr Malin highlighted the lack of significant differences in outcomes or toxicities.

“When [these drugs] have been com­pared head to head, there are modest differences in survival, generally on the order of about 6 weeks,” Dr Malin said. “When you look at toxicities, they don’t differ that much across the regimens.”

What was striking, however, was the difference in cost, which ranges from $450 for 4 cycles to $65,000 for 4 cycles, depending on the regimen.

This is a situation where we see a very big difference in value, Dr Malin said.

Pathway Initiative

To reward high-value care, Anthem’s health plan introduced an initiative called the Cancer Care Quality Program.

“What a pathway does is try to identify the most high-value regimens and put them out there as a benchmark,” she explained. “Oncologists participating in the Cancer Care Quality Program will receive additional payment for treatment planning and care coordination when they select a treatment regimen that is on pathway.”

Clinical pathways promote regimens that are supported by evidence and clinical guidelines, and are aligned with health plan medical policies. Pathways are intended to be applicable for 80% to 90% of patients and are selected based on clinical benefit, side effects and toxicities, the strength of national guideline recommendations, and cost.

“The additional payment is $350 per month while the member is on active therapy,” said Dr Malin. “So, it’s not tied with a specific visit, it allows the practice to use that money for care coordination..., and it’s not tied to the cost of the drugs that they use.”

Rewarding for Outcomes

According to Dr Malin, the clinical pathway is intended to reverse the current healthcare model, which rewards practices for using more expensive drugs with greater revenues.

Anthem started this program in July 2014 with pathways for breast, lung, and colorectal cancers, and has since grown to include 10 different tumor types, representing 90% of the chemotherapy regimens that can be administered to its members.

“In September, there were 616 practices participating, and that included about 5500 members. On average, it was about 9 patients per practice,” Dr Malin said. “We now have approximately 8 million Anthem members who are covered by this program.”

Anthem has expanded the program to California, Colorado, Nevada, and New York, with plans to include the rest of its Northeast member states and Virginia in the fall.

Network feedback, which is submitted through Anthem’s webinars, has thus far been positive. “Pathways are the future, and adhering to pathways will enhance revenue. Also, cost containment by insurance company,” commented one person.

In the first 6 months of the program, the adherence rates to the pathway for breast, colorectal, and lung cancers were 63%, 72%, and 63%, respectively.

Last modified: August 30, 2021