Controlling Oncology Costs with Cross-Benefit Drug Management

October 09, 2023 - The oncology care landscape is dynamic, shaped by rising cancer medication expenses, medical advancements, and the persistent influence of outside challenges like COVID-19. To navigate this complexity and its implications for future cancer care, cross-benefit drug management intervenes to tackle challenges and offer solutions. 

The Rising Tide of Cancer Medication Costs 

The continuous influx of new cancer drugs and indications renders the landscape highly complex. "In a typical year, the FDA greenlights 10–15 new cancer drugs, and groups like the National Comprehensive Cancer Network (NCCN) identify 30–40 new indications for existing drugs, signifying frequent changes," Tim Foley, Vice President of Product, Oncology, at Optum, told PharmaNewsIntelligence. 

While beneficial, the abundance of treatment options often comes with a hefty price tag. For example, Merck's PD-L1 inhibitor, Keytruda, has received approval for over 15 different uses in recent years, but the expense to patients for each dose, when administered every three weeks, surpasses $10,000.

Across other types of cancer, such as colon cancer, there are over 100 potential regimens. Foley noted that while this innovation provides great benefits to cancer patients who would have few options previously, this continuous progression has introduced significant cost challenges for healthcare providers, payers, and patients. 

Additionally, the COVID-19 pandemic has introduced new complexities. While some studies suggested a decline in cancer screenings during lockdowns, the full ramifications on cancer progression and costs are still under scrutiny. Foley explained that the research community is still evaluating whether the pandemic has resulted in more patients developing more advanced cancers that may be more expensive to treat.

Foley elaborated on the pandemic's impact — highlighting a temporary reduction in providers seeking prior authorizations — and emphasized that cancer treatment remained necessary even during the pandemic, causing the trend to reverse quickly.  

“Overall, the trend of more drugs, high costs, and complexity has continued through and after COVID,” stressed Foley. 

A New Strategy for Managing Cancer Costs

Specialty Fusion, Optum's solution for managing specialty drugs across both the medical and pharmacy benefits, focuses on tackling rising costs, especially in cancer medications. What sets Specialty Fusion apart is its comprehensive provider decision support, which consolidates all available clinical and financial treatment details during the prior authorization process to recommend the best possible care choices to providers. 

"Specialty Fusion utilizes a decision engine, enabling providers to efficiently identify a comprehensive array of potential medications suitable for the patient, their specific condition, and other parameters provided by the clinician," explained Peter Demogenes, Vice President of Product at Optum. 

In the realm of cancer care, Specialty Fusion extends its capabilities beyond traditional utilization management programs by examining clinically appropriate treatment types, associated sites of care, and other financial factors on both medical and pharmacy benefits. This comprehensive approach enables Specialty Fusion to create tailored care plans that optimize patient outcomes while ensuring lower costs. 

"Specialty Fusion can examine all influencers of specialty drug spend simultaneously at the point of request, identifying the best medication, regimen, or sequence, commonly referred to as a Pathway, to address the patient's care over time,” Demogenes added. 

Keeping Current on Oncology Guidelines 

Foley emphasized the critical role of evidence-based care in Specialty Fusion's decision-making process. The tool stays current with the latest clinical guidelines, including those from the National Comprehensive Cancer Network (NCCN). Foley emphasized their team of oncology pharmacists who diligently review evidence updates to ensure that Specialty Fusion's recommendations align with the most current medical guidance. 

"A team of oncology pharmacists carefully reviews ongoing evidence updates, including those mentioned earlier from organizations such as NCCN. They assess FDA approvals for new drugs and indications while monitoring changes in Medicare rules like national and local coverage determinations,” Foley continued. “This comprehensive analysis helps to determine how the evidence has evolved regarding the appropriateness of drugs for specific conditions." 

Specialty Fusion takes an even more extensive approach by integrating Optum Pathways that encourage providers to select evidence-based treatments with high efficacy, low toxicity, and low total cost of care. 

"With the inclusion of the Pathways, the tool can take it a step further,” Foley added. “For instance, in the case of first- and second-line metastatic colon cancer, there are 108 regimens that are used for cancer patients — there might be 75 that are evidence-based and just 33 that we’d encourage within our Pathways due to superior evidence and toxicity." 

Clinical Appropriateness vs. Cost-Effectiveness 

Balancing clinical appropriateness with cost-effectiveness in treatment recommendations is a critical consideration. Foley highlighted the importance of Specialty Fusion's pathways in guiding providers toward evidence-based options that optimize efficacy, quality, and total cost of care.  

"Pathways underscore our dedication to evidence-based care by refining recommended options using data to evaluate the total cost of care associated with different treatments," clarified Foley.   

To illustrate the real-world impact of Cancer Guidance Program (CGP) pathways adherence (vs off-pathway), Foley provided a detailed case study involving actively treated breast cancer patients in the Commercial population. By guiding providers to on-pathway treatments, CGP Pathways achieved a 12% lower cost for on-pathway vs off-pathway cancer patients, with savings of around $1,300 per diseased patient per month. On-pathway regimens for Breast cancer were also associated with 18% fewer all-cause inpatient admits, 14% fewer cancer-related inpatient admits, and 18% fewer all-cause inpatient admits. This demonstrates how evidence-based decision support can significantly reduce costs without compromising patient care. 

Impact on Costs and Outcomes  

The discussion then shifted to the innovative cancer support program within Specialty Fusion. While drug costs comprise a significant portion of cancer treatment expenses, Foley highlighted that addressing other factors can also lead to cost reductions.  

Optum’s Cancer Support Program manages avoidable inpatient expenses, such as unplanned admissions and emergency room visits. "About 50–55% of its cancer costs are driven by drug spend, and about 15–20% of the costs are inpatient spend, a large majority of which is avoidable," Foley pointed out. 

The Future of Cross-Benefit Drug Management Solutions 

Demogenes outlined Optum's vision for cross-benefit drug management, emphasizing better integration among payers, providers, and patients to make informed decisions collaboratively. 

“The core tenets encompass a straightforward and user-friendly solution, seamless integration with electronic medical record and electronic health record systems, and a collaborative shared decision-making model," he revealed. 

Demogenes also highlighted several key areas of focus, including the following. 

• Integrating the four Ps: Ensuring that payers, providers, patients, and platforms can access the same information, fostering collaboration and informed decision-making. 
• Expanding decision support: Continuously improving the decision engine by incorporating all data influencing specialty care, allowing for more nuanced decision-making. 

• Health equity: Utilizing data to address health disparities by tailoring care to individual patients and demographic groups. 
• Value-based care: Embracing value-based care models that prioritize patient outcomes and cost-effectiveness. 
• Patient engagement: Enhancing patient engagement through digital tools, remote monitoring, and telehealth to improve care coordination and adherence. 

By fostering collaboration and transparency, these solutions can help healthcare stakeholders navigate the complexities while ensuring patients receive the most appropriate and cost-effective care. 

As Foley and Demogenes demonstrated, the success of Specialty Fusion lies in its ability to consolidate vast amounts of clinical data, stay aligned with the latest guidelines, and guide providers toward evidence-based, cost-effective treatments. This holistic approach delivers substantial cost savings and ensures patients receive the best possible care, representing a promising path forward in oncology management. 

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