Managing Complexity in Oncology

Specialty Pharmacy TimesMay/June 2015
Volume 6
Issue 3

Recently published data from a survey of commercial health plans reveal the latest trends and emerging strategies in oncology management.

Recently published data from a survey of commercial health plans reveal the latest trends and emerging strategies in oncology management.

Oncology therapies were responsible for 13% to 25% of recent specialty drug costs in the United States, according to pharmacy benefit management (PBM) trend reports.1 A robust pipeline (Table 1) of new therapies designed to address the needs of the 14.5 million people living with cancer all but ensures that efficient management of oncology care will continue to be a priority for health plans and other managed markets stakeholders.2 Looking at the challenges payers anticipate and how they plan to handle them can help guide treatment management decisions in this important category.

This year, 70 commercial health plans representing more than 102 million covered lives contributed to the EMD Serono Specialty Digest, now in its 11th edition and available online at Commercial health plans participating in the survey represent all regions of the United States and all types of plans, including national, regional, and state plans. Sixteen percent of survey respondents represent national plans, 41% represent regional plans, and 43% represent statewide plans.1 The survey included health plan pharmacy directors (n = 60), medical directors (n = 9), and other (n = 1) who are primarily responsible for overseeing specialty drug—related services in their organizations. Data discussed represent only the results of the survey, unless otherwise noted.1

Oncology Management is Evolving

Health plans are rapidly evolving their management of oral and infused oncology drugs, supportive care therapies, and companion diagnostics as the cost of treatment and the wide variation in care and outcomes become more apparent. Payers are developing new initiatives that focus on adherence to evidence-based guidelines, engaging their members in active management of their disease, and promoting the use of palliative care to provide holistic support for members.

Payer goals related to oncology management encompass economic, clinical, and quality parameters (Table 2). The actual achievement of these goals is in its early stages, where less than 25% of payers indicated they have been effective at achieving most of these goals. One notable exception is that 46% of plans indicated they have been effective at promoting the use of evidence-based guidelines to oncologists.1

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A number of utilization management strategies reported in the survey also target oncology as part of general, enterprisewide initiatives1:

  • 63% of plans require prior authorization (PA) for infused oncology
  • 97% of plans use partial fill programs that target oral oncology
  • 25% of plans with site-of-service programs address infused oncology
  • Pilot episode-of-care (EOC) reimbursement programs are deployed for various cancers

Management of oncology drugs is a top priority for plans:

  • 79% of payers said that oncology management was their top specialty drug challenge
  • 43% of plans indicated that management of oncology drugs was their top management goal for specialty drugs for 2014

Increasing Use of Clinical Pathways

Among payers, 21% (representing 37% of lives) indicate they have implemented oncology clinical pathways, with another 24% (representing 11% of lives) intending to implement oncology pathways in the next 12 months (Table 3).1

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Anticipated savings from oncology pathway programs are modest, but increasing. At the time of the survey, 56% of plans saw savings of 1% to 6%.1 Of these plans currently using pathways, 69% utilize a third-party vendor to manage the pathways and 38% collaborate with oncologists to develop the pathways. Plans are less likely to create their own proprietary pathways (25%) or rely on oncologists to develop their own pathways (19%).1

Adopting Multiple Pathway Components

Oncology pathway programs may include a number of components related to diagnosis, treatment, and supportive patient care (Table 4):

  • Drug therapy (oral and infused oncology, supportive care, and companion diagnostics), radiation therapy, and advanced imaging are the most common components of current oncology pathways
  • Palliative care, end-of-life care, and surgery are less commonly included in current clinical pathways; however, some health plans with clinical pathway programs anticipate including these components in the future

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Physician Incentives for Pathway Use Vary

Of the 16 plans with clinical pathways, 87% offer 1 or more incentives to physicians for participating in pathway programs. Incentives include1:

  • A bonus for adherence to guidelines (50%)
  • Shared savings from medical cost reductions (31%)
  • Flat fee for use of pathways (31%)
  • “Gold card” MDs to eliminate PAs (13%)

Of these plans, 75% make the use of pathways voluntary.

Increasing Focus on Palliative Care and End-of-Life Care

More than 50% of plans are focusing their efforts on educating providers on the appropriate use of palliative care. A variety of strategies are being utilized to provide more palliative care and end-of-life care for patients with cancer (see Sidebar and Table 5).

Companion diagnostics are utilized to select the appropriate and optimal therapies based on a patient’s genetic composition or other molecular or cellular analysis. These tests determine which patients will respond to treatment, who is at risk for specific adverse events, and the appropriate dose.

Almost two-thirds of payers currently require companion diagnostic testing before approval of oncology drugs and restrict use of the drugs based on the results of the test (Table 6).1 Plans appear to be nearly evenly divided on whether they require submission of test results or accept attestation of test results from a provider. Only 11% of plans currently cover whole tumor genome sequencing.

Future Management Strategies

The majority of strategies focus on medical benefit management, including site of service, outpatient hospital and infusion network contracting, and molecular diagnostic management. In addition, payers cited new benefits designs, partial fill, and PA enforcement as strategies they intend to implement in the next 12 months (Table 7).1

On the other hand, respondents had consistent approaches to what strategies they do not plan to implement in the next 12 to 24 months. Strategies payers were least likely to implement include1:

  • Relaxing PA requirements
  • Implementing EOC reimbursement
  • Lowering specialty drug cost share

Making Trend Data Work for Your Organization

Monitoring utilization management trends in high-cost therapeutic areas can help you stay competitive by identifying key areas for further evaluation. Careful assessment of new strategies, based on your knowledge of the populations you serve and your organizational resources, is the first step to developing cost-effective programs that meet both clinical and business objectives. SPT


EMD Serono Specialty Digest

, 11th Edition, is available in both digital and print formats at The website also invites health plans to sign up to participate in next year's survey.


  • EMD Serono. EMD Serono Specialty Digest. 11th ed. Darmstadt, Germany: EMD Serono; 2015. Accessed April 28, 2015.
  • American Cancer Society. Cancer Facts & Figures 2015. Atlanta, GA: American Cancer Society; 2015. Accessed April 28, 2015.
  • More than 400 innovative medicines in development for top chronic diseases affecting older Americans [press release]. Washington, DC: Pharmaceutical Research and Manufacturers of America. March 20, 2013. Accessed April 28, 2015.
  • Medicines in Development: Cancer. Washington, DC: Pharmaceutical Research and Manufacturers of America. 2014. Accessed April 28, 2015.
  • National voluntary consensus standards: palliative care and end-of-life care. National Quality Forum website. Accessed April 28, 2015.

About the Authors

Brenda Motheral, RPh, MBA, PhD, is the president and cofounder of Artemetrx. In this role, Brenda oversees the Artemetrx Specialty Drug Solutions and Artemetrx Health teams of research and analysis experts to bring innovation and thought leadership to the pharmacy and medical benefits industries. She previously held the position of executive director of the Pharmacy Benefit Management Institute, as well as leadership management positions at Healthways and Express Scripts. Dr. Motheral has worked with more than 50 plan sponsors in the last 3 years on the analysis, design, and implementation of specialty drug solutions. She has published more than 50 peer-reviewed manuscripts and has received national research awards from the Academy for Managed Care Pharmacy and the International Society for Pharmacoeconomics and Outcomes Research. She received her PhD in health economics from the University of South Carolina and her MBA and a BS in pharmacy from the University of Kentucky.

John Neal, MBA, is the vice president of US Managed Markets Payer Marketing at EMD Serono. In this role, John manages the annual development and execution of EMD Serono US Market Access for its key brands. John also supported development of the 11th edition of the EMD Serono Specialty Digest. He previously held leadership positions in sales, marketing, and managed markets at GlaxoSmithKline and Novartis. Mr. Neal holds an MBA in international marketing from Drake University and a BS in chemistry from the University of Illinois.

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