Redefine payer-provider relationships to reduce cancer costs


There is no denying it--cancer is expensive. Although less than 1 percent of the commercially-insured population has cancer, they account for more than 10 percent of all healthcare costs. The average cost of one episode of chemotherapy is $138,000.

"Oncology is a big cost driver for us," Dr. Kristen Andersen, Chief of Staff to the Chief Medical Officer at Aetna, said during a recent AHIP virtual seminar. The insurer wanted to do something to address the costs. "We didn't want a typical role. We didn't want to go down the path of treatment plan reviews," she said. Instead, Aetna (NYSE: AET) is collaborating with physicians to improve the quality and efficiency in cancer care to reduce costs.

"The collaborative relationship helps change the delivery of care to one that focuses on and rewards quality outcomes over volume in treatment. Most importantly, we can give patients access to more effective cancer care with fewer side effects, less time in treatment and lower costs," Andersen told me in a follow-up interview.

"We realized that we need better alignment to bring about this high-quality medical system that we could afford. So we set about to redefine traditional provider-payer relationships," Andersen added.

Andersen cited an Aetna-U.S. Oncology study that found evidence-based care for patients with non-small cell lung cancer resulted in an average cost savings of 35 percent. "This is a great example of cancer care that can save patients--and the nation's healthcare system--millions of dollars and produce equally effective results," she said.

The study spurred Aetna to create its Oncology Solutions program that aims to improve quality and efficiency in oncology care by working collaboratively with the clinical community to make cancer care more effective, affordable and safer. "Our approach to cancer care covers everything from diagnosis to treatment, adjuvant therapies, radiation treatment and palliative care," Andersen said. 

Clinical pathways are a cornerstone of Aetna's oncology program. They provide the medical evidence to help doctors make treatment decisions and improve quality. "Pathways discourage unnecessary therapies, help patients navigate the system, minimize side effects and toxicities for patient and respect end-of-life decisions--all critical elements," noted Andersen. Additionally, the program is changing drug reimbursement so the pathways that drive selection of most cost-effective medications can also be profitable for oncologists. "Pathways must keep physicians whole," Andersen said, or providers will not successfully adhere to them.

When asked how other insurers considering similar programs could ensure their success, Andersen told me they must recognize that "collaboration is the key to improving outcomes." Additionally, Aetna believes the following elements are critical to a successful payer-provider relationship:

  • Back the medical community in its effort to identify the best evidence and treatment practices.
  • Support patients getting proactive support throughout treatment and end-of-life care planning.
  • Help doctors adopt health information technology for advanced decision support.
  • Be open to appropriate payments that give doctors incentives to follow evidence-based standards.
                                                                                    - Dina

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