As health plans and major employers initiate so-called cancer-management programs, oncology practices are bracing for a new level of interaction with—and scrutiny from—health care payers.
The latest example comes from CIGNA HealthCare, which will launch an oncology condition-management program in January. That program uses disease-management and case-management concepts to target CIGNA members being treated for active disease, as well as cancer survivors and members at high risk of cancer.
CIGNA is following the lead of several other major insurers. Among them:
- UnitedHealth Group, through a comprehensive cancer-management program announced this summer, funnels cancer patients to providers that participate in its “centers of excellence” program and provides case management intervention.
- In April, Aetna added cancer to its disease-management lineup when it announced Aetna Health Connections, which the company called “a new approach to medical management.”
- Humana in 2005 began offering cancer-management services through a contract with Quality Oncology, a unit of Matria Inc., one of the nation's largest disease-management companies.
In business since the early 1990s, Quality Oncology is considered the “granddaddy” of the cancer-management providers. Using case management and, for some clients, utilization-management strategies, the company works not only for health plans, but also directly for major employers, such as Delta Airlines.
Same Stated Goal: To Improve Health Outcomes While Decreasing Costs of Care
Although the programs differ in their details, all have the same stated goal: to improve health outcomes while decreasing costs of care. The National Cancer Institute reports that direct medical costs for cancer care in 2004 totaled more than $72 billion, a figure that is expected to rise steeply with the increasing incidence of cancer in America's aging population and the advent of expensive new treatment options.
Cancer-management programs are payers' attempt to grapple with the fact that, unlike protocols for many health conditions, best practices for cancer treatment are not entirely settled.
“Right now there is no definitive information that says, by golly, we know you're doing a good job,” said Denise Pierce, President of DK Pierce and Associates, a reimbursement planning and health policy firm based in Zionsville, IN. “All they see right now is there's a lot of money going out of the insurance company and they don't understand why.”
Through the new programs, insurers are trying to learn how oncologists practice with the goal of establishing standards, such as those in the pay-for-performance programs that are emerging in primary care and some other subspecialties.
“They say, ‘We want to help direct what we think might be the best practice,’” Ms. Pierce said. “And that's where oncologists say, ‘You have no idea what it takes to care for a cancer patient.”
Build on Success of Other Disease-Management Programs
The cancer-management programs emerge as payers rapidly build on their success with disease-management programs that target diabetics, asthma patients, and individuals being treated for a handful of other chronic conditions. In those cases, insurers who have found ways to increase patient compliance with treatment protocols have seen hospitalizations—and the costs associated with them—fall.
An oncology practice administrator for more than 15 years, Judy Stone, administrator at Carolinas Hematology-Oncology Associates in Charlotte, NC, understands the payers' concern—but she does not appreciate their approach.
“I've watched cancer go from a death sentence to a chronic illness so I do understand why the insurance companies and the nation in general are concerned about health care costs and cancer,” she said. “But the case manager is not really there to help the patient, although that's the face they put on. The case manager is there to protect the bottom line.”
Those who are developing the cancer-management programs counter that their goal is to improve patients' health status, which has the happy side effect of curtailing costs. A primary strategy is making oncology nurses available by telephone around-the-clock to help patients manage the side effects of treatment so that they stay out of emergency rooms and inpatient beds.
“A classic case—somebody will be dehydrated, present at an ER, get admitted, and stay for 10 days,” said Charles Kanach, President and Chief Operating Officer at Quality Oncology in Vienna, VA. “They pick up some other kind of infection and there's another subsequent complication that occurs. There's 10 days of hospitalization that could be avoided.”
Thus, he and other cancer-management providers say that, by helping patients manage the side effects of their treatment, they are supporting oncologists and cancer patients and saving money while doing so. Other key activities: helping patients make decisions about treatment options, coaching them to consider end-of-life decisions at the appropriate time, and suggesting ways to afford therapies that are not covered by their health plan.
Peter D. Eisenberg, MD, a partner in California Cancer Care Inc. in Greenbrae, CA, said he considers such services to be a waste of money.
“I frankly don't need a patient-management company to tell me that stuff,” Dr. Eisenberg said. ''That's what I went to med school for, and that's why I did a fellowship in oncology.
“We're looking out for the best interest of our patients, and we structure our interaction around explaining to patients what their options are and helping patients come to decisions based on what's best for them,” he continued. “For a patient to get a call from a nurse in Florida to be sure that the patient is getting the information she needs to make a decision and is otherwise feeling cared for is redundant.”
Some cancer-management programs go beyond services for patients with active disease to also target those who are at high risk of a cancer diagnosis or recurrence. David Ferriss, MD, Medical Director for CIGNA HealthCare, said his company will focus on a continuum of care services designed to prevent cancer, diagnose it early, treat it effectively, and avoid recurrence.
For example, CIGNA will use claims data and health risk-assessment data to identify high-risk members who have not had recommended screenings and contact them personally to encourage compliance.