Expert Q&A With Jennifer Malin
Anthem and the Alliance for Health Reform recently cohosted a Capitol Hill briefing on new models of cancer care, which explored how payers, providers and other stakeholders are working to reshape the current oncology care delivery and payment systems. After the briefing, ThinkAnthem caught up with Jennifer Malin, MD, PhD, Medical Director for Oncology for Care Management at Anthem to discuss what Anthem is doing to improve cancer care across the country.
Anthem recently launched its Cancer Care Quality Program to promote the use of proven cancer therapies and reduce variation in treatment across the country. Would you describe how the program is structured to achieve its expert goals?
We are working with oncologists to transform cancer care in American by rewarding oncologists for choosing high quality, high value treatments. This is the right thing for members of our affiliated health plans. Our members and our customers have growing concerns about the lack of transparency regarding the quality and cost of cancer care.
There should be a strong connection between the quality and value of the care, the innovation and the price paid for it.
Anthem, along with AIM Specialty Health, has developed the Cancer Care Quality Program in collaboration with oncologists working in large teaching hospitals and independent practice. This program identifies certain cancer treatment pathways selected based upon current medical evidence, peer-reviewed published literature, consensus guidelines, and Anthem’s clinical policies, to support oncologists in identifying cancer treatment therapies that are clinically effective and provide greater value.
It will also allow oncologists to compare planned cancer treatment regimens against evidence-based clinical criteria and potentially receive enhanced reimbursement. To be eligible for enhanced reimbursement, oncologists must be in-network for the member’s health benefit plan and select a cancer treatment regimen that is designated as a cancer treatment pathway.
In the future, one of our goals of the program is to be able to make data on the cost of cancer treatment options available to our members along with information about how often their oncologists follow evidence-based pathways, empowering our members to be better informed health care consumers.
The Cancer Care Quality Program creates pathways for physicians to use as decision support with members in a way that members get clinically appropriate, quality care with minimal side effects at the best cost. Ultimately, Anthem believes the Cancer Care Quality Program will serve as the industry standard for measuring and paying for evidenced-based oncology treatment planning and care with the goal of ensuring appropriate, quality care and transparency for the member while also keeping members’ benefits affordable.
We’re looking at the regimens that produce the best outcomes. For example, for those who have been diagnosed with Her2 positive breast cancer, Kadcyla may be the best choice. Kadcyla, which is on pathway, improves survival by six months but costs about $9,000 a month – far more than other drugs. However, in non-small cell lung cancer, six platinum-based regimens range from $450 to over $60,000 in costs with no difference in outcomes. In this case, the regimens that are equally as effective but cost less are on pathway (four of the regimens are on Pathway ranging in cost from $450 to $25,000).
Given the many different types of cancer and many different types of cancer patients, this program must have taken quite a bit of time and talent to develop. Would you tell us a bit about how it came together?
Sure. Initially, we didn’t seek to create our own pathways. As we began evaluating other pathways, we determined that we wanted a more robust process to guide the creation of the pathways. And, other vendors or companies would not just license their pathways. They wanted to sell both their interface system and their pathways.
The pathways are developed starting with the medical evidence and national clinical guidelines, such as National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) guidelines, which also are used for developing Anthem medical policy. The pathways are then reviewed by external advisors that consist of about dozen geographically diverse physicians who are actively treating patients and work in academic and community oncology groups and have specific interest in quality of care. Six members of the committee are on faculty or affiliated with the National Cancer Institute (NCI) designated cancer centers, seven are affiliated with Blue Centers of Distinction, four are in community practice settings, and six have served on national committees for organizations such as National Quality Forum (NQF), ASCO, and the Institute of Medicine (IOM) to improve the quality of cancer care.
The committee uses a process similar to how we evaluate drugs chosen for our drug formularies. The group evaluates the evidence for given treatments and compares outcomes for each –much like a comparative effectiveness review. Then, they compare costs of those regimens with the best outcomes.
The Cancer Care Quality Program is the first of its kind to be rolled out on the scale that it is. Given the breadth of its application, what successes have you seen so far? Where do you see room for improvement?
So far, we’ve seen quick adoption of the program—not only in numbers of cases coming through but in how quickly oncologists and their staffs have been able to navigate the program, designed for its ease of use. In developing and implementing the program, we’ve engaged with advocacy groups, oncologists, oncology societies, and pharmaceutical companies at a deeper level. This interaction has been helpful in understanding their perspectives. In the end, we want the same thing – the most effective cancer treatment with the least side effects and greatest quality of life at the lowest cost.
As far as room for improvement, we have been asked some questions about how we are communicating with members about the changes. Since we didn’t previously communicate with members about oncology quality and how their oncologists were being reimbursed, we had not considered this. Since we plan to share some of the results with consumers on how various practices adhere to pathways and other quality measures such as those recommended by ASCO and the Community Oncology Alliance (COA), this is something we are now considering.
What are the next steps for the program?
We originally started the program with pathways for breast, lung, and colorectal cancer. Recently, we added pathways for melanoma, myeloma, lymphoma, leukemia, ovarian, pancreatic, and brain cancers. Pathways for Chronic Myelogenous Leukemia (CML) and prostate cancer are expected in early 2015. We’ll continue talking to providers to see what other types of cancer pathways are helpful.
We launched in July in Indiana, Kentucky, Missouri, Ohio, Wisconsin and Georgia. And, then we launched at the beginning of this month in California, Colorado and Nevada. We’ll add New York, Connecticut, Maine and New Hampshire in 2015.