October 25, 2021
Cancer is a leading cause of death in the United States, second only to heart disease, and clinicians are diagnosing more cases than ever before.1 The cost of caring for cancer patients has also reached all-time highs, with total spending on cancer-related health care in the U.S. expected to grow to $246 billion by 2030, up 34% from 2015.2 Without a doubt, it is the largest driver of health care spending in the United States.1
Often masked by this grim reality are modern beacons of hope that speak to just how far we’ve actually come in fighting this disease. Clinical innovation has ultimately extended patient lifespans and, for many, has turned cancer into a chronic disease. In fact, the dramatic cost equation that we see today is due, in large part, to advanced treatments and increased survivorship (patients living longer and thus requiring treatment for a longer duration of time). The population of cancer survivors now exceeds 15 million. What’s especially noteworthy is that approximately one half of these individuals are of working age.3
Growing Employer Impact and Responsibility
Such dramatic innovation in the field requires increased attention from employers. New treatment pathways and early detection options, for example, mean better patient results. Employers can help ensure ease of access to innovation and offer navigation support to those employees on an increasingly complex cancer journey – a journey now largely characterized by highly specialized treatment options, variability of outcomes and various new touchpoints with the health care system. Employers also have a responsibility to closely monitor and evolve alongside the oncology treatment landscape as a way of better managing escalating treatment-related costs. Cancer consistently falls among an employer’s top two highest cost drivers and drastically influences cost trend, which is likely to accelerate in the face of clinical innovation and a rapidly evolving drug treatment pipeline.
Emerging changes in how care is being delivered may also require that employers take another look at their programs and partnerships to ensure that they are making way for virtual expansion and positive shifts in site of care, which increasingly focus on combining academic cancer center expertise with the ease and convenience of community oncology. Naturally, if the mode of delivery is changing, employers may soon need to consider alternative methods of payment as well.
The growing number of cancer survivors in the workplace is also an important consideration. Given that cancer is such a tremendous driver of lost productivity, supporting these employee patients appropriately will contribute to enhanced work-related focus and retention.
With significant cause to turn greater attention to the oncology space, progressive employers are stepping up to keep pace with emerging trends in cancer care, namely 1) precision medicine advancements impacting both prevention/early detection and treatment landscapes; 2) a shift in site-of-care; 3) an evolution of oncology payment models; 4) enhanced patient experience; and 5) a growing culture of support and accommodations within the workplace. Each of these trends are actively shaping affordability (for patient and employer), quality, patient experience and outcomes.
The following sections highlight key considerations pertaining to each of these five trends and offer relevant recommendations intended to help employers stay ahead of the curve.
Stellar Advancements in Screening, Early Detection and Treatment: The Role of Precision Medicine
A recent McKinsey and Company report stated that “oncology is at the vanguard of precision medicine.”4 Indeed, while advanced precision medicine is making its mark on countless treatment landscapes, it has had the most dramatic impact within the oncology sphere. Genomic science, in particular, is completely transforming cancer prevention and treatment protocol, raising new considerations for employers concerning cost, value and vendor partnerships.
Screening and Early Detection
While the latest genomic innovations are taking the cancer detection landscape by storm, routine preventive screenings (e.g., colonoscopies, mammograms, pap smears and lung imaging for high-risk patients) remain an important component of routine patient care and are critical to early disease detection. Alarmingly, we’ve seen a significant decline in such cancer screenings, and thus diagnoses, (down 74% between April 2019 and April 2020) due to the COVID-19 pandemic.5 This trend, of course, has led to widespread concern that delayed detection will lead to later-stage diagnosis, increased risk of cancer death and more substantial treatments costs, impacting both the patient and payer. Employers have a role to play in calling attention to this startling reality and in deploying appropriate communications to their workforce that encourage a return to routine care (For a more in-depth perspective on regulatory framework and specific cancer screening guidelines please refer to our Employers’ Guide to Preventive Care).6
While we may not be able to make up for lost ground entirely in the shadow of COVID-19, advancements in genomic medicine have brought cancer screening and early detection to new levels and may be able to help fill in some of the gaps.
Predictive genetic testing can identify genetic mutations and/or other indicators that can predict the likelihood of developing different types of cancers. Some genetic discoveries may drastically influence the screening frequency or course of treatment that a patient undergoes (e.g., a woman with the BRCA1 or BRCA2 mutation may require mammograms earlier in life and more frequently to increase the likelihood of early detection). This type of testing is usually reserved for those who have a known family history of certain types of cancer. Please refer to Section 3 of the Business Group’s Employers’ Guide to Precision Medicine7 for more on predictive genetic testing for inherited cancer susceptibility and associated coverage recommendations from the United States Preventive Services Task Force (USPSTF).
Beyond predictive testing, there are new diagnostic testing solutions in the field that can help confirm an actual diagnosis of cancer (versus risk) that may be suspected due to patient signs and symptoms. The latest testing solution under this umbrella allows a physician to test a patient for a broad array of cancers all at once with a single blood draw. If cancer is developing somewhere within the body, this test will identify tumor DNA particles that have shed into the patient’s bloodstream and map the type and exact location of the growing cancer. This type of testing is primed to become an important early detection asset and may, in the near future, completely transform routine cancer screening protocols.
Following cancer detection, proper diagnosis and course of treatment will increasingly rely on the ability to identify specific cancer-causing gene mutations. Biomarker testing (a type of diagnostic based on gene expression profiling and proteomics) can provide critical information on how cancer cells (blood or solid tumor) are behaving (i.e., how aggressive) and the potential course of drug treatment they’re likely to respond to. A physician may decide on a suitable drug regimen with the help of either a companion or comparative diagnostic test. For more information on these types of diagnostic tests, please refer to Section 6 of the Business Group’s Employers’ Guide to Precision Medicine.7
A key challenge currently lies with ensuring that all newly diagnosed and eligible cancer patients go on to receive appropriate biomarker testing. There seems to be underutilization of certain biomarker tests despite strong evidence for use, an example being testing for the EGFR mutation for lung cancer patients.8
The liquid biopsy is completely transforming the broader diagnostics space, playing a role in early detection, determining initial course of treatment and monitoring disease progression and evolution throughout the body.9 This type of test offers a less expensive and non-invasive alternative to the traditional biopsy and works by identifying protein-based biomarkers in a patient’s blood or urine.9,10
“Although liquid biopsies still are being researched, the potential they offer to provide a new way to monitor the presence of cancer, track cancer’s response to treatment and watch for a recurrence of cancer using a blood test could be a significant step forward in cancer care.”
— Dr. Minetta C. Liu, Medical Oncology, Mayo Clinic, Rochester, Minnesota 9
Nanotechnology also holds tremendous promise in the evolving early detection space, with innovative imaging tests that can now more accurately depict the location of a patient’s tumor(s). This technology may also aid in more effective drug delivery to cancer cells.11
Modern-day Evolution of Cancer Treatment
Fortunately, innovation in precision medicine has expanded its reach beyond screening and early detection and into the realm of therapeutics, increasingly giving cancer patients a fighting chance at long-term survival. Once an individual has officially been diagnosed with cancer, precision medicine strategy focuses on how that patient’s genes (or tumor cell genes) are behaving and might affect course of treatment.
When we talk about precision medicine in oncology treatment, we are referring to “targeted therapies,” which are designed to interfere with, or target, specific cancer molecules (often proteins) or the cancer-causing genes that generate them. A genomic test (like those referenced above) will determine if the patient has the gene or enough of the targeted protein to warrant a particular therapy (often either a small molecule drug or a monoclonal antibody). These therapies can be given in pill form or as an infusion, often alongside chemotherapy or radiation.12 Unlike chemotherapy and radiation, however, they leave normal healthy cells intact and simply zero in on the disease-causing mechanism of the cancer cell itself.13 The NIH National Cancer Institute (NCI) has compiled a list of approved targeted therapies that are available and in use today.14 Gene therapies and immunotherapies, standouts on the list, are causing quite a stir in the media for their patient success stories and jaw-dropping price tags.
Gene therapies are used in instances where a gene or part of a gene is defective or missing from birth or where a mutation has occurred due to environmental or lifestyle factors in adult life. Ultimately, these drugs are designed to replace such missing or faulty genes or “knock out” a mutated gene that is functioning abnormally and causing harmful effects (e.g., the proliferation of cancer cells).15 While the innovation is inspiring, million-dollar price tags increase the volatility of health care expenses and threaten the sustainability of affordable coverage. Beyond the price tag of the gene therapy itself are costs associated with its complex administration (e.g., extended hospital stays and supplementary services and medications).16 For more on patient experience, coverage considerations and plan management approaches to gene therapies, please refer to Section 5 of the Business Group’s Employers’ Guide to Precision Medicine.7
Immunotherapy drugs, on the other hand, selectively target aspects of the patient’s immune system to optimize the body’s innate response to invading cancer cells. It was discovered in the 1990s that cancer cells can take advantage of naturally occurring molecules that turn off the body’s immune response to tumors.15 Immunotherapies help turn the immune response back on. T-cell therapy or CAR T-cell therapy is a groundbreaking immunotherapy approach that involves removing a number of T cells from a patient’s tumor, genetically modifying them in a lab setting to enhance their cancer-fighting ability and then implanting them back into the patient. CAR T-cell therapy is an example of an immunotherapy that happens to also be a gene therapy. There is a great deal of intersection between these two innovative treatment approaches. Importantly, both stand in stark contrast to conventional treatment (i.e., radiation and chemotherapy), where all cells are destroyed or damaged during treatment, including the healthy ones.
Like gene therapies, immunotherapies also have hefty price tags. For example, a popular CAR T-cell therapy, KymriahTM, costs $475,000 per year to treat acute lymphoblastic leukemia in children and young adults. This number does not even take into account the wraparound costs associated with the drug’s administration (e.g., physician expertise, extended hospital stay and supporting therapeutic agents/equipment). For more on immunotherapy cost, patient experience and eligibility, please refer to the Business Group's Immunotherapy: Revolutionizing the Cancer Treatment Landscape.17
There is no denying that advances in precision medicine, namely in the field of genomic science, have completely transformed cancer detection and treatment paradigms. While all this innovation holds tremendous promise for squashing late-stage diagnoses and dramatically improving cancer prognoses, the evidence is still nascent at this point. There is far more ground to cover and much for employers to consider in the way of patient experience and coverage strategy. The key for employers will be to follow the evidence and to strike a balance between advancing innovation and supporting the sustainability of employer-sponsored coverage in the face of staggering cost projections.
Employer Recommendations for Staying Ahead of the Curve
- 1 | Monitor the rapidly evolving genetic testing landscape as it relates to cancer and engage with your health plan partners to understand their coverage policies and ensure that these policies adhere to clinical guidelines. Any considerations for enhancing coverage for some tests beyond what is recommended by the health partners’ formularies and coverage guidelines should be evaluated by clinical experts familiar with the latest evidence.
- 2 | Consider pairing genetic counseling with genetic testing to assist with test interpretation and appropriate next steps.
- 3 | Even employers who have not made an active coverage decision with their partners with respect to genetic testing may already be paying for these tests and can expect the trend to increase. Consider implementing routine claims reporting that can help identify potential areas of opportunity for better utilization management for genetic testing and identify areas of potential abuse/waste.
- 4 | Ensure that any testing and/or associated support programs you implement encourage personalized shared decision-making between patient and provider that hinges on a patient’s level of risk, individual set of circumstances and preferences.
- 5 | Don’t lose sight of routine cancer screenings. Consider launching a workforce campaign that reminds and encourages employees to follow up on missed screenings that fell through the cracks due to COVID-19 and underscore the ease of newer, non-invasive, at-home screening options.
- 6 | Actively monitor the oncology drug pipeline and new treatment developments and request that your plan partners provide advanced notification when an anticipated high-priced oncology therapy may come to market. Request reports with potential cost and utilization impact as well as treatment safety and efficacy considerations.
- 7 | Ask your partners about how they are adjudicating therapies and set expectations for how you will collaboratively determine future treatment adjudication [e.g., prior authorization (PA) and step- therapy protocol]. Evaluate the effectiveness of the PA process amid emerging personalized clinical pathway guidelines. Discuss specific guidelines regarding off-label use of treatments not currently approved by the Food and Drug Administration (FDA).
- 8 | Ask what value-based, outcomes-based and/or risk-sharing payment models plan partners may be considering with manufacturers and ensure that policies are being updated in response to the release of outcomes data from ongoing clinical trials for drugs that had previously received accelerated approval.
- 9 | Create urgency with plan partners around integrated total cost of care forecasting and implications.
- 10 | Determine, with your partners, how best to educate and encourage employee patients to seek possible enrollment in a relevant targeted therapy clinical trial, particularly where there is an unmet clinical need or where off-label prescription coverage is denied by the health plan.
- 11 | Consider exploring and partnering with a cancer Center of Excellence (COE) that is well-equipped, from a staffing and infrastructure perspective, to administer and monitor proper gene therapy or immunotherapy treatment.
A Shift in Site of Care
Complementing clinical innovation is an ever-evolving approach to where and how patients receive their oncology care. In recent years and months, the oncology care landscape has witnessed 1) a significant shift toward incorporating the use of telehealth and other digital platforms in patient care, 2) an enhanced reliance on at home testing and treatment options, and 3) the emergence of new models that seek to combine the best elements of community oncology and academic cancer centers.
From In-person Clinic Visits to Telehealth
Beginning in 2020, due to the COVID-19 pandemic, cancer care providers were reporting a notable shift from in-person clinic visits to telehealth.18 While the industry as a whole gravitated toward the use of virtual platforms during this time, oncology centers, by and large, led the charge. In order to mitigate exposure and prevent transmission of COVID-19 to high-risk and vulnerable cancer patients, oncology protocols were adjusted considerably, patients were urged to stay home, and more opportunities were created for virtual care delivery.19
The sudden rise of telehealth utilization in the oncology setting warranted a set of parameters or a “playbook” for implementation. The American Society of Clinical Oncology (ASCO) created a set of standards and practice recommendations in response to this need, highlighting situations where telehealth may be appropriate over in-person care and vice versa. Telehealth visits are most recommended for things like medication prescribing and management; prechemotherapy and other pretherapy evaluations; acute care issues that could be addressed via routine outpatient vs. emergency department visits and admissions; discussion of results from laboratory tests and imaging studies; supportive care visits; and chronic care management. In-person visits may be encouraged for initial consultations, initial delivery of antineoplastic treatment, conveying key information (e.g., new cancer diagnosis or treatment plan, relapse or progression) and complex cancer needs as identified by the oncologist.20 For a full list of standards and practice recommendations, click here.
While cancer patients have historically preferred to seek in-person care, modern telehealth options are becoming increasingly more attractive, even beyond the scope of the pandemic. Not only do they help mitigate a cancer patient’s risk of deadly infection, they’ve also been shown to provide faster, less expensive care. Telehealth may play a future role in keeping burgeoning cancer costs in check.1 From a patient experience standpoint, a shift to increased virtual provider interface means a great deal of added convenience to an otherwise generally inconvenient cancer journey (and from an employer standpoint, less impact on employee productivity/time away from the office). The question now remains: Are many of these virtual protocols here to stay? All roads point to “yes” – virtual health will remain, and evolve into, an important component of cancer care delivery. Health plans have been closely examining this trend and are considering any necessary changes to reimbursement policies associated with virtual care delivery.21
The integration of digital tools [e.g., wearable devices, remote health sensors/monitors, electronically recorded patient-reported outcomes (PROs)] with telehealth is another important component of the virtual/site-of-care evolution. Through routine, remote evaluation of a patient’s functional status, a physician can make more informed clinical decisions (e.g., decide on whether chemotherapy would be appropriate for a patient based on overall health status).22 From a patient experience standpoint, these devices limit the amount of face time needed in the oncologist’s office and empower patients to take control of their health, potentially enhancing quality of life and bolstering recovery efforts.
Increase in At-home Testing and Treatment
The dramatic reductions in cancer screenings, leading to a lack of early detection amid the COVID-19 pandemic, ominously hint at increased cancer incidence and greater morbidity and mortality in the months and years to come. In fact, according to Business Group on Health’s 2022 Large Employers Health Care Strategy and Plan Design Survey, 68% of employers anticipate a higher prevalence of late-stage cancers in their population due to delayed screenings. This reality has created a strong case for home-based cancer screening and perhaps has even accelerated its path forward.
Home cancer screening can be taught to patients and performed by them and then integrated directly into provider workflow, making it an effective early detection and follow-up tool.23 Currently, at-home screening tests are largely geared toward colorectal, prostate, breast ovarian and cervical cancers. There are some multicancer blood tests that patients can do at home that screen for a number of these (and more) simultaneously. These panel blood tests have been shown to have extremely high sensitivity and specificity rates and can fully discriminate between each cancer type. Cancers that do not currently have established screening methods (e.g., liver and pancreatic) may become excellent candidates for at home liquid biopsy screens.24 Many believe that the future of cancer screening, especially after COVID-19, may be at home.23
Coinciding with a rise in home-based testing efforts is a growing interest in home-based treatment options. At-home cancer treatment has historically been uncommon in the U.S. due to a preference for built-in safety guarantees within the outpatient and inpatient settings, deep-rooted insurance benefit design and cancer drug reimbursement policies (often higher reimbursement rates for infused and injected drugs given in the outpatient setting). Global estimates demonstrate that approximately 5%-10% of cancer patients receive their treatments at home. Low-complexity infusions (e.g., hydration and other supportive treatments) and over 20 chemotherapy agents have been safely administered this way, resulting in improved patient and caregiver experience at lower costs.25
The pandemic, and the dramatic reduction in in-person visits, sparked an expansion of home infusion services in the U.S., and in many cases, led to patients being switched to oral oncology medications (as opposed to infused therapy) through telehealth counseling. Patients were also counseled on subcutaneous injections that could be administered at home and were switched to products with longer dosing intervals. Many cancer centers anticipate that, even long after the pandemic, patients will continue to opt for home-based care.18 Patients may, however, continually be steered to the outpatient setting as health systems struggle to regain lost revenue due to the pandemic.25
Community Oncology versus Prestigious Academic Cancer Center: Leveraging the Best of Both Worlds
A cancer patient will typically receive care at a physician’s office or community oncology clinic, a hospital outpatient department or a hospital inpatient department (a destination most often reserved for the sickest patients).26
There are strong and longstanding opinions about the benefits of a patient being treated at a community oncology practice vs. an academic cancer center – each capable of supporting the patient care journey with a unique set of strengths. There is growing acknowledgment in the field of the merits of a combined approach, which has led to the emergence of an innovative care model that weaves together the very best elements of both. This new approach allows patients to remain at home with their community oncologist surrounded by family while supported by state-of-the-art NCI-designated comprehensive cancer center expertise throughout the entire cancer care journey.
Spotlight on Access Hope
Founded by NCI-designated comprehensive cancer center, City of Hope, to extend world-class cancer expertise to patients across the country, the Access Hope model supports patients receiving care from their local physicians and enables proactive, timely and seamless access to cutting-edge information, diagnostics and treatment plans as well as personalized support, navigation and expert advice throughout the care journey. An employer-facing model that also ties directly into health plans (supplementing and providing what they can’t), Access Hope targets addressable gaps in optimal care and disparities in health outcomes that occur across site of care and zip code.27
Finally, it’s worth noting that there is potential for new industry partnerships that may lead to additional shifts in site of care. The pandemic has ignited new partnerships – perhaps most famously, those of manufacturers who came together to build a COVID-19 vaccine. As the demand and costs for oncology treatments rise, companies across the industry may look to secure an edge in the marketplace and build a more viable business strategy by working together.21
Employer Recommendations for Staying Ahead of the Curve
- 1 | Work with your plan partners to ensure that standards and practice recommendations for telehealth usage in oncology are being adhered to in order to maximize the value of patient in-person versus virtual visits.
Employer Use of Cancer COEs Trending Upward
Large employers are increasingly contracting with, and sending employees to, cancer COEs to attain more favorable patient outcomes and financial arrangements. Although travel to COEs was severely hindered most recently by COVID-19 pandemic restrictions, resulting in an increased reliance on local care, COE momentum/utilization will likely pick back up in the coming years. According to the 2022 Large Employers’ Health Care Strategy and Plan Design Survey, by 2022, 45% of large employers will have a cancer COE arrangement in place, with this number jumping 23 percentage points to 68% by 2023/24.
- 2 | Work with your plan partners to determine a coverage strategy for at-home testing methods and consider reviewing age limits for preventive screening.
- 3 | When deciding on a site-of care strategy, engage with local community providers as well as academic cancer centers to discuss measures and quality outcomes, volume and staff expertise. Work with your partners to understand precisely what types of metrics you should be asking for. Consider partnerships/new solutions that involve leveraging the best of what academic cancer centers and community oncology have to offer.
- 4 | Steer patients to providers that have access to clinical pathways (i.e., tools used to guide evidence-based cancer care).
- 5 | As there may be an opportunity for employers to reduce spending through site-of-care policies that encourage home treatment for certain oncology drugs, ensure that benefit design does not obstruct home administration of cancer treatments. Work with your partners to understand which treatments are suitable and safe for home administration and which should primarily be administered in an outpatient setting.
Evolution of Payment Models
There is a tremendous opportunity for progress in emerging payment models for cancer care in the U.S., in large part because there are significant reasons why the predominant fee-for-service model of reimbursement is particularly bad for cancer treatment. This model incentivizes higher utilization of services and screenings that may not be necessary, with reimbursements that carry no ties to quality of care, adherence to standardized treatment pathways, outcomes, and patient experience. Fee-for-service reimbursement disincentives lower cost and use of convenient sites of care. For a complex condition like cancer, these practices result in dozens or even hundreds of bills to manage.
Some key issues include:
- A significant portion of cancer care is for pharmaceuticals administered under the medical benefit, which means they’re often reimbursed on a buy-and-bill model that inflates costs.
- Drug costs regularly rise – something that providers cannot control – so many alternative payment models will exclude pharmaceuticals, which have a major impact on cancer care and costs.
- Use of expensive drugs is rewarded while valuable care is undercompensated.
The buy-and-bill process involves a health care provider purchasing, storing and administering a drug product to a patient. Once the drug is administered, a medical claim is submitted, and the provider is reimbursed at ASP+6% under Medicare Part B.
- Many cancers are misdiagnosed, and the unnecessary treatment for incorrect diagnoses or later-stage diagnoses can be very expensive; fee-for-service (FFS) reimbursement still pays fully for this sometimes-inappropriate care.
- There are several public and private payer approaches to value-based cancer care, which can create administrative burden and complexity for oncologists participating in them.
If we are able to better align incentives for patients, oncologists and their teams, employers and health plans, there is a great opportunity to improve the accuracy of diagnoses, the effectiveness of treatment, outcomes for patients, and the significant spending associated with cancer care. Several approaches to doing this are outlined below, all of which seek in some way to move away from the basic fee-for-service model. However, it’s worth noting that there are dozens of cancers with very different treatment regimens, rapidly evolving evidence, and levels of prevalence – all of which can make the development of value-based arrangements especially challenging.
Bundled Payments for Cancer
Patients in treatment for cancer receive a large number of bills from a significant number of specialists over time. This can be confusing for patients who receive hundreds of charges, difficult to manage from a health plan perspective and costly for self-insured employers (and their employees) who are paying for every discrete service whether or not it is absolutely necessary and evidence based. Paying for cancer care with bundled payments solves some of these challenges. A bundled payment covers a set of health care services over a discrete period of time. If costs of care run over the dollar value of the bundled payment, providers are on the hook for the cost overrun and won’t be reimbursed more. If they manage to help patients stay healthy (e.g., preventing infections that require hospitalizations for immunocompromised cancer patients), practice evidence-based medicine following Oncology Clinical Pathways28 and deliver care under the value of the bundled payment, providers can keep the unused funds.
While bundled payments are traditionally used for more common procedures with shorter periods of treatment and follow-up (e.g., a joint replacement), emerging evidence suggests that it is possible to maintain similar outcomes and achieve significant cost savings through cancer bundles for certain more routine and predictable cancers.29 By paying oncologists up front for a negotiated rate that is estimated to cover 6 or 12 months-worth of treatment based on past billing, they are able to be more flexible in how they deliver care. Providers can then use the funds they received to hire additional staff (e.g., care coordinators, palliative care support, integrated mental health professionals, nutritionists) to support people outside of the office to help them stay healthy. If successful, a bundled payment results in comprehensive care with fewer bills to manage and improved patient experience and outcomes.
Bundled payments for cancer care need to have flexibility included in them to account for significant changes in a patient’s health status and treatment regimen – a possibility given the complexity, high risk and longitudinal nature of treatment for many cancers. Not all cancers will be covered by bundled payments, and even for those that are, it’s likely that earlier stage cancers will be more suitable for these arrangements given the increased uncertainty for someone who discovers a late-stage cancer.
For many years, several vendors have provided second-opinion services for many treatments, though cancer care is covered less prevalently than other conditions due to its complexity. Some health systems that operate as COEs for cancer care have begun offering second-opinion services of their own that stand apart from traditional ongoing care, though a second opinion delivered by one of these COEs could certainly lead to care delivered by that health system. Payment for cancer care, whether provided by a COE or a community care clinician, can be tied to the use of a second opinion service. It would be an aggressive step to require a second opinion before any ongoing treatment is delivered outright across your population, but this is beginning to emerge at high-performing COEs (will conduct second opinions before even seeing a patient in an attempt to efficiently secure diagnosis and treatment plan).
Second opinions for cancer care have evolved over time to address the real need to extend the expertise of cancer experts in limited locations to other community physicians around the country. These second- opinion providers may simply review patient records and scans to provide their analysis of an initial diagnosis and treatment plan, or they may require patient travel to a COE to obtain additional testing before a medical opinion is delivered. As patients transition back home, second-opinion providers can continue to consult with community physicians from afar about the course of care for that patient. Particularly for rare cancers, a community oncologist may have encountered only a handful of them over the course of their career, whereas a focused cancer treatment center may treat several such diseases every year.
Patient-Centered Medical Homes (PCMHs), Accountable Care Organizations (ACOs) and Capitated Arrangements (Capitation)
What do these models have to do with cancer? Given the significant amount of spend associated with cancer care, providers in any of these reimbursement models are going to need to manage spending related to cancer or face significant financial challenges at the end of the year. Employers considering these models should ask participating providers how these arrangements help them better manage cancer care. Importantly, not all broad-scale payment models like these hold providers responsible for pharmaceutical spending, so employers interested in impacting a key condition like cancer through these models should look into whether their contracts include drug spending as part of the overall financial performance.
Employer Recommendations for Staying Ahead of the Curve
- 1 | Alternative payment models for cancer care are designed to enable providers to best care for their patients, not necessarily or solely to cut costs. Tying payments to high-quality cancer care and improved outcomes is appropriate and achievable for many types of cancer. Therefore, it may be a good idea to explore such models with your health plans or most prevalent providers.
- 2 | Communications to employees about any value-based oncology care program should focus on what is achieved through alternative payment models, such as improved diagnoses, connection to top facilities, support from clinicians outside of the doctor’s office, and other services.
- 3 | Check to see if pharmaceuticals are included in payment reform contracts, especially since the bulk of spending for many cancers is on pharmaceuticals. While providers can’t control whether drug costs rise (they probably will) or new drugs come onto the market (they may, and will be expensive if they do), they have more power than anyone to decide which drugs their patients receive. Therefore, contract language can be put in place to protect them from unforeseen developments outside of their control.
- 4 | Focus on your top areas of cancer spend first. From there, look at the data, understand the most prominent needs and then seek out vendors that may be able to address them.
- 5 | Evaluate the value of emerging end-to-end cancer solutions that aim to guide people who receive a cancer diagnosis through the course of their treatment. This approach includes comprehensive care management, high-performance provider selection, return-to-work support, and other assistance. These programs tend to partner with high-performing cancer centers and then help employees transition back to their community providers.
Growing Emphasis on an Enhanced Patient Experience
As described by the Agency for Healthcare Research and Quality (AHRQ), patient experience “encompasses the range of interactions that patients have with the health care system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other health care facilities.” An integral component of health care quality, patient experience takes into consideration aspects of care such as timely appointments, easy access to information and seamless communication with health care providers.30 Given the complexity of a cancer diagnosis, the magnitude of symptoms and their impact on both physical and mental well-being, and the sheer number of patient health care interactions that follow, it quickly becomes clear why patient experience must be the focal point of effective oncology program design.
In an effort to improve the patient experience, many employers are deploying comprehensive, evidence-based tools and solutions that employees can tap into. Increasingly, employers are leveraging expanding virtual health capabilities, partnering with navigation and advocacy/support vendors, partnering with cancer COEs offering superior expertise and experience, launching end-to-end solutions, and placing increased emphasis on health equity and diversity initiatives.
Research demonstrates that only 12% of people have sufficient health literacy skills to navigate our exceedingly complex health care system.31 This reality, combined with the inherent mental, physical and emotional drain associated with navigating the cancer patient journey, creates an enormous need for specialized guidance and support. This need is magnified by the growing complexity and specialization of the early detection and treatment landscape. Now, more than ever, the emphasis is on catching patients early in their journey through the use of effective and timely data and deploying communications that can ultimately direct them to the best site of care possible.
Employer Recommendations for Staying Ahead of the Curve
- 1 | Ask your vendor partners to share with you standardized and validated measures of the patient experience that you, providers and the patient can rely on.
- 2 | Work with your health plan, pharmacy benefit manager (PBM) and other partners to build a comprehensive cancer management program that provides navigation, second-opinion and decision-support services.
- 3 | Ensure that your second-opinion program offering engages its experts with the patient’s treating oncologist.
- 4 | Consider offering online patient support networks through your employee assistance program (EAP) vendor partner. These support networks have been linked with improvements in the mental and emotional well-being of the patient.32 Online cancer patient communities provide a broad network of support that can be widely accessed and utilized by patients across a vast spectrum of cancer diagnoses.
- 5 | The pandemic has highlighted and, in some cases, worsened existing inequities within the cancer treatment realm—especially as they relate to patient experience.33 Consider the role of social determinants of health (SDOH) and how they are linked to patient experience and outcomes. 34 Then aim to offer support programs and services that align with specific employee needs.
Creating a Culture of Support in the Workplace
With a growing number of patients remaining active in the workplace at all stages of cancer treatment, employers are increasingly looking for ways to support a healthy work-life balance that can both practically and mentally/emotionally ameliorate the patient’s entire cancer care journey. As a bonus to enhanced patient well-being, workplace support goes a long way in optimizing productivity/ROI where an employee is still willing to, and capable of, work.
It goes without saying that a cancer diagnosis and associated treatment places a great burden on a patient’s physical and mental capacity and, to a large extent, disrupts the ecosystem within which they live and work.35 Adverse physical effects from cancer treatments and chemotherapy have been shown to diminish worker capacity and outcomes.36 Estimates reveal that one in four cancer survivors feel less productive at work and experience difficulty performing physical tasks. Many (~14%) find mental tasks equally burdensome.35 Overall, cancer treatment and caregiving account for nearly $139 billion in reduced workplace productivity and lost work hours.37 This impact on the individual may even have a negative ripple effect on the overall morale and productivity of surrounding team members and staff.36
Beyond physical and mental stressors, cancer patients face an enormous financial burden – a burden that will likely only increase, given what we’ve seen from new-to-market entrants and future pipeline projections. Notably, “financial toxicity” has been linked to a greater risk of mortality, poorer overall well-being, and impaired quality of life for cancer patients.38
Given the tremendous physical, mental and financial stressors that follow a cancer diagnosis, a workplace culture of support and understanding is integral to helping patients succeed at work and feel supported.
Employer Recommendations for Staying Ahead of the Curve
- 1 | Consider providing specific resources and training to managers so they are well equipped to appropriately support cancer patients in their active participation in the workplace. Encourage supervisors to respect, listen and understand. Leaders and colleagues should recognize that it is solely the employee’s personal choice to disclose when, what and with who(m) they share their cancer diagnosis in the workplace.
- 2 | Make your HR team an integral component of the cancer patient’s support team. There may be some employee hesitancy about discussing leave and other accommodations directly with a supervisor. HR may serve to proactively step in and facilitate these meetings between supervisors and employees.
- 3 | A caregiver is a lifeline to a cancer patient. Employers should consider building on this support system and extend benefits and communication efforts to meet the dynamic needs of both patients and their caregivers (whether the caregiver is the primary employee or the family/friend at home).
- 4 | Be sure to connect your employees to specialized resources. These may include care coordination/navigation support services, second-opinion tools, mental health resources, Employee Resource Groups (ERGs) and other free online support groups such as the Cancer Survivors Network. Employees will likely have a number of questions about the tools and services available to them during cancer treatment; chances are they will be unaware that certain resources even exist. Employers should consider amplifying messaging about these resources and providing appropriate and timely steerage toward them.
5 | Consider on-site support services and workplace modifications to better accommodate working cancer patients, particularly those undergoing active treatment:
- Parking spaces closer to the office entrance.
- Private space for employees to take medication.
- Additional time for project deliverables.
- Periodic mindfulness breaks.
- Reduced and/or modified job responsibilities. This can be done by reassigning certain tasks to other team members where appropriate (e.g., limited physical responsibilities).
- Suitable office temperature.
- 6 | Consider approaches to allow cancer patients increased flexibility, such as expansion of part-time or full-time remote options, flexible release for appointments/treatments and restructuring of job responsibilities/priorities.
More TopicsData Insights Plan Design & Administration COVID-19
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