Population
health management strategies such as precision medicine, coordinated care, and
value-based payment models can improve patient outcomes.
February 07,
2020 - The industry’s transition into value-based care is
characterized by a focus on data and patient centered care. By driving strong
population health management, payers can excel in this value-based care model
that relies on quality measures and patient outcomes to define successful care.
Driving population
health management is most needed but also particularly challenging for
populations with complex, chronic diseases such as cancer.
Cancer presents a
population health challenge due to its many varieties. There are more than 100
known types of cancer, according to the National Cancer
Institute.
Another difficulty in
treating cancer with population health management is the population size. At
the dawn of 2019, over 16.9
million cancer survivors in the US alone and experts expect
that number to reach 22.1 million by 2030.
Cost of care also
inhibits value-based cancer care. In 2019, cancer costs in the US
reached $150 billion, driven largely by drug costs but also personal
travel expenses for appointments and other hidden costs.
Population health
management can help manage costs, keep out-of-pocket healthcare spending low
for patients, and implement treatment early to improve downstream patient
outcomes.
Payers who practice
precision medicine to determine diagnoses early, structure their care
coordination effectively, and engage in value-based payment models in their
oncological care will be able to boost patient outcomes.
USE
PRECISION MEDICINE FOR DIAGNOSIS AND TREATMENT
Payers may consider
precision care models that utilize gene therapies to both diagnose and treat
cancers. So far, solutions have centralized on ovarian and breast cancer, both
of which can be genetically-inherited diseases.
There are three
recent developments currently at payers’ disposal, including next generation
sequencing, BRCA, and chimeric antigen receptor (CAR) T-cell therapy.
CMS just
recently announced that
it would cover next generation sequencing for inherited breast and ovarian
cancers. The test evaluates a patient’s genetic makeup to guide providers
toward the most effective solution.
As a result, the
payer and patient can save the expense and exhaustion of experimenting with
multiple therapies before finding one that works. It can also be useful for
identifying patients who would qualify for clinical trials.
Aetna was the first
to develop BRCA gene testing. The genes BRCA1 and BRCA2 have been found in both
ovarian and breast cancer patients.
Though the population
of women who develop ovarian or breast cancer is small, the number of women who
have BRCA1 or BRCA2 within this population is highly significant, according to
the National Cancer
Institute.
Seventy-two percent
of women who inherited BRCA1 and 69 percent of those who inherited BRCA2
genetic mutations will develop breast cancer. Meanwhile, 44 percent of women
who inherit BRCA1 and 17 percent who inherit BRCA2 will develop ovarian cancer.
Given the prevalence
of the BRCA genes in the small patient populations who have these diseases,
these gene tests are seen as very useful when a trend toward ovarian or breast
cancer has already manifested itself in the family history, according to the
National Cancer Institute.
In addition to
supporting next generation sequencing in order to identify a treatment option,
CMS finalized a decision to provide Medicare coverage for the biological
therapy known as CAR T-cell.
The first
FDA-approved gene therapy, CAR T-cell is used to treat Hodgkin lymphoma and
B-cell precursor acute lymphoblastic leukemia. Two kinds of CAR T-cell
therapies were available at the time of this article’s publication:
tisagenlecleucel (Kymriah) and axicabtagene ciloleucel (Yescarta).
The procedure
genetically alters the patient’s T-cells, reprogramming them to fight the
cancer. While it is still too early to assess outcomes of this treatment, some
studies have seen a 90 percent success rate among B-Cell Acute Lymphoblastic
Leukemia children and adults who had seen multiple relapses or had not
responded to other therapies, according to the Leukemia and
Lymphoma Society.
By choosing to cover
these diagnostics and treatments, payers expand cancer patients’ options for
care.
ENGAGE IN
INTEGRATED, COORDINATED CARE
Payers can
successfully pursue oncological population health management through integrated
and coordinated care.
Such programs may
assign an oncology care coordinator to each patient, whose task will be to
coordinate the entire care team.
When designing their
care teams, payers can also think beyond medical care to identify patients’
needs.
Integrating benefits
navigation, home healthcare, and oncology care into one team for each patient
can help ensure that the payer’s oncology population is supported by holistic
care.
Cigna lately implemented one
such model in its partnership with Memorial Sloan Kettering.
The care team
consists of an MSK oncology certified registered nurse as an oncology care
coordinator, a collaborative care associate from Cigna to help with benefits
navigation, and an oncology case management team available to assist with
non-clinical needs.
The care team is
engaged in the full continuum of care, including the clinical treatments,
discharge and transfer to the patient’s primary care provider, follow up, and
palliative or end-of-life hospice care.
“Cigna's success with
Collaborative Accountable Care arrangements has helped our customers receive
higher quality care and value, while making access to treatment more
affordable,” said Laura Reich, MD, market medical executive for Cigna.
ALIGN
FINANCIAL INCENTIVES THROUGH VALUE-BASED PAYMENT MODELS
The payer-provider
relationship can undergo some tension when pursuing population health
management. When payers’ and providers’ visions for care are at odds with each
other, it can be hard to initiate coordinated care, much less pursue innovative
diagnostic and treatment solutions.
Value-based payment
models can help align payer and provider incentives to achieve successful
population health management.
Humana’s value-based
care oncology program, called the Oncology Model
of Care (OMOC) program, uses a value-based payment model to
align incentives with its providers. These arrangements are upside-risk.
The major payer
evaluates access to care, clinical status assessments, and patient education to
ensure quality care. The payer observes both quality and cost to determine
whether the provider is offering value-based care.
Payers can select
from a multitude of metrics to check providers’ quality. Humana chose to examine
the quality and cost of care in the following five areas:
·
Inpatient admissions
·
Emergency room visits
·
Medical and pharmacy drugs
·
Laboratory and pathology services
·
Radiology
Population health
management can be a challenge when the health condition is as complex as
oncological care. Using precision medicine, integrating and coordinating their
care, and aligning with their providers through value-based payment models are
strong first steps toward value-based cancer population health management.
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