Population health management strategies such as precision medicine, coordinated care, and value-based payment models can improve patient outcomes.
The industry’s transition into value-based care is characterized by a focus on data and patient centered care. By driving strong population health management, payers can excel in this value-based care model that relies on quality measures and patient outcomes to define successful care.
Driving population health management is most needed but also particularly challenging for populations with complex, chronic diseases such as cancer.
Cancer presents a population health challenge due to its many varieties. There are more than 100 known types of cancer, according to the National Cancer Institute.
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Another difficulty in treating cancer with population health management is the population size. At the dawn of 2019, over 16.9 million cancer survivors in the US alone and experts expect that number to reach 22.1 million by 2030.
Cost of care also inhibits value-based cancer care. In 2019, cancer costs in the US reached $150 billion, driven largely by drug costs but also personal travel expenses for appointments and other hidden costs.
Population health management can help manage costs, keep out-of-pocket healthcare spending low for patients, and implement treatment early to improve downstream patient outcomes.
Payers who practice precision medicine to determine diagnoses early, structure their care coordination effectively, and engage in value-based payment models in their oncological care will be able to boost patient outcomes.
Payers may consider precision care models that utilize gene therapies to both diagnose and treat cancers. So far, solutions have centralized on ovarian and breast cancer, both of which can be genetically-inherited diseases.
There are three recent developments currently at payers’ disposal, including next generation sequencing, BRCA, and chimeric antigen receptor (CAR) T-cell therapy.
CMS just recently announced that it would cover next generation sequencing for inherited breast and ovarian cancers. The test evaluates a patient’s genetic makeup to guide providers toward the most effective solution.
As a result, the payer and patient can save the expense and exhaustion of experimenting with multiple therapies before finding one that works. It can also be useful for identifying patients who would qualify for clinical trials.
Aetna was the first to develop BRCA gene testing. The genes BRCA1 and BRCA2 have been found in both ovarian and breast cancer patients.
Though the population of women who develop ovarian or breast cancer is small, the number of women who have BRCA1 or BRCA2 within this population is highly significant, according to the National Cancer Institute.
Seventy-two percent of women who inherited BRCA1 and 69 percent of those who inherited BRCA2 genetic mutations will develop breast cancer. Meanwhile, 44 percent of women who inherit BRCA1 and 17 percent who inherit BRCA2 will develop ovarian cancer.
Given the prevalence of the BRCA genes in the small patient populations who have these diseases, these gene tests are seen as very useful when a trend toward ovarian or breast cancer has already manifested itself in the family history, according to the National Cancer Institute.
In addition to supporting next generation sequencing in order to identify a treatment option, CMS finalized a decision to provide Medicare coverage for the biological therapy known as CAR T-cell.
The first FDA-approved gene therapy, CAR T-cell is used to treat Hodgkin lymphoma and B-cell precursor acute lymphoblastic leukemia. Two kinds of CAR T-cell therapies were available at the time of this article’s publication: tisagenlecleucel (Kymriah) and axicabtagene ciloleucel (Yescarta).
The procedure genetically alters the patient’s T-cells, reprogramming them to fight the cancer. While it is still too early to assess outcomes of this treatment, some studies have seen a 90 percent success rate among B-Cell Acute Lymphoblastic Leukemia children and adults who had seen multiple relapses or had not responded to other therapies, according to the Leukemia and Lymphoma Society.
By choosing to cover these diagnostics and treatments, payers expand cancer patients’ options for care.
ENGAGE IN INTEGRATED, COORDINATED CARE
Payers can successfully pursue oncological population health management through integrated and coordinated care.
Such programs may assign an oncology care coordinator to each patient, whose task will be to coordinate the entire care team.
When designing their care teams, payers can also think beyond medical care to identify patients’ needs.
Integrating benefits navigation, home healthcare, and oncology care into one team for each patient can help ensure that the payer’s oncology population is supported by holistic care.
Cigna lately implemented one such model in its partnership with Memorial Sloan Kettering.
The care team consists of an MSK oncology certified registered nurse as an oncology care coordinator, a collaborative care associate from Cigna to help with benefits navigation, and an oncology case management team available to assist with non-clinical needs.
The care team is engaged in the full continuum of care, including the clinical treatments, discharge and transfer to the patient’s primary care provider, follow up, and palliative or end-of-life hospice care.
“Cigna’s success with Collaborative Accountable Care arrangements has helped our customers receive higher quality care and value, while making access to treatment more affordable,” said Laura Reich, MD, market medical executive for Cigna.
ALIGN FINANCIAL INCENTIVES THROUGH VALUE-BASED PAYMENT MODELS
The payer-provider relationship can undergo some tension when pursuing population health management. When payers’ and providers’ visions for care are at odds with each other, it can be hard to initiate coordinated care, much less pursue innovative diagnostic and treatment solutions.
Value-based payment models can help align payer and provider incentives to achieve successful population health management.
Humana’s value-based care oncology program, called the Oncology Model of Care (OMOC) program, uses a value-based payment model to align incentives with its providers. These arrangements are upside-risk.
The major payer evaluates access to care, clinical status assessments, and patient education to ensure quality care. The payer observes both quality and cost to determine whether the provider is offering value-based care.
Payers can select from a multitude of metrics to check providers’ quality. Humana chose to examine the quality and cost of care in the following five areas:
- Inpatient admissions
- Emergency room visits
- Medical and pharmacy drugs
- Laboratory and pathology services
Population health management can be a challenge when the health condition is as complex as oncological care. Using precision medicine, integrating and coordinating their care, and aligning with their providers through value-based payment models are strong first steps toward value-based cancer population health management.
Source: Health Payer Intelligence