Oncology P4P program boosted evidence-based care

November 18, 2020 | by Angela Maas

Carelon Research partnered with the University of Pennsylvania, Carelon Insights, and Elevance Health on a study of the Cancer Care Quality Program treatment pathways used in Elevance Health-affiliated health plans.

The study  highlights the power of a pay-for-performance oncology program to boost evidence-based care. This study, published in the Journal of Clinical Oncology, is featured in the following article in Radar on Specialty Pharmacy.

This article was originally published by AIS Health  and has been reproduced with permission.

Oncology P4P program boosted evidence-based care

A recent study of the Cancer Care Quality Program (CCQP) treatment pathways found that an enhanced reimbursement to providers who adhere to on-pathway treatment regimens increased use of the drugs without changing the total care spending, supporting the payer’s efforts to move the needle on value-based care. That program has since led to the insurer’s launch of an oncology medical home this summer.

Elevance Health launched CCQP in 2014, rolling it out to 14 states through the next year (RSP 6/14, p. 3). Administered by Carelon Insights, the voluntary program provides enhanced reimbursement of $350 for a person’s initial on-pathway treatment and then $350 every month after for a maximum number of months as specified by CCQP. Those payments are in addition to reimbursement for office visits and drugs. There’s no penalty if a provider chooses an off-pathway regimen.

Researchers were trying to determine whether providers in the pay-for-performance (P4P) program were prescribing a CCQP-endorsed, evidence-based treatment regimen. They looked at pharmacy and medical benefit claims for people at least 18 years old diagnosed with breast, colon or lung cancer between July 1, 2013, and Sept. 30, 2017, and tracked them through March 30, 2018. More than 1,800 oncologists and 25,000 people were included across 14 states, and spending over a six-month episode period was evaluated.

According to the article, which was published on the Journal of Clinical Oncology’s website Oct. 7, Elevance Health’s program is the largest P4P program focused on the use of evidence-based oncology medications in the U.S. Over the study period, 97% of eligible providers opted to participate in CCQP.

Researchers found that prescribing an evidence-based regimen rose from 57.1% of patients to 62.2% of patients during the study period. In addition, spending on oncology drugs increased $3,339, and member out-of-pocket spending rose $253. However, “no significant changes in total health care spending” were detected.

Per the article, “Changing physician practice patterns is challenging. In the case of cancer drug prescribing, this may be a result, in part, of financial incentives in the buy-and-bill system, where physicians receive greater remuneration when prescribing higher-priced cancer drugs regardless of evidence. Our findings also revealed substantial variation in cancer drug prescribing. Physicians prescribed 402 unique drug regimens even though only 60 of those regimens were program-endorsed, evidence-based regimens.”

“We are not aware of interventions at a national scale that have been as effective in changing cancer drug prescribing patterns as CCQP,” maintains the article. “The success of CCQP in changing prescribing patterns is particularly relevant because P4P is widely used by insurers and health care delivery organizations as a means to improve quality, reduce costs, or both.”

Findings echoed those of United study

The article points out that researchers’ conclusion that the program was associated with increased oncology drug spending was consistent with a similar finding in a study of a UnitedHealthcare oncology pilot (RSP 8/14, p. 1). “Given the high cost of cancer drugs, including evidence-based cancer drugs, increases in evidence-based prescribing may not be enough to influence spending,” concludes the article. “Collectively, these findings suggest that, in cancer care, paying physicians bonuses to prescribe evidence-based cancer drugs may improve care quality but may not yield savings. Furthermore, increases in evidence-based prescribing alone, regardless of intervention, may not be sufficient to bend the cost curve in cancer care, where unplanned acute care (hospitalizations and emergency department visits) also drives substantial spending.”

“In this study, we found that a voluntary pay-for-performance program for oncology sponsored by a national insurer increased prescribing of evidence-based cancer drugs without changing overall spending,” says the lead author of the study, Justin Bekelman, M.D., director of the Penn Center for Cancer Care Innovation at the Abramson Cancer Center and a professor of radiation oncology in the Perelman School of Medicine at the University of Pennsylvania. “This is a big deal, given how important evidence-based cancer drug prescribing is to achieving the best possible outcomes in cancer care.”

Asked about some of the most surprising or noteworthy findings of the study, he tells AIS Health that “it was notable that even though the program worked — that is, it was effective in increasing evidence-based prescribing — it did not generate savings during the short-term, six-month episode of care we analyzed. This points to the need to evaluate longer-term spending, as evidence-based cancer drugs are not only more effective but also tend to be less toxic, likely reducing downstream costs of cancer care.”

Longer evaluation time may be needed

In response to the same question, David DeBono, M.D., Elevance Health’s national medical director for oncology and a co-author of the study, says, “we expected that this type of quality program would also drive lower costs because more effective and less toxic therapies tend to reduce downstream costs of care. Our expectation was based on our ongoing actuarial analyses of the full spectrum of pathways evaluated over a longer time frame of nine months or more where we clearly and consistently see downstream savings. However, based on the limited spectrum of clinical scenarios evaluated in this study and the short, six-month time frame used for the analyses of downstream costs, there were no differences in costs of care.”

CCQP is “fundamentally unchanged” from how it was when it started, says DeBono. “However, as we collect data on practice patterns and share these data with practices in a collaborative manner, new opportunities have taken root, including an Oncology Medical Home initiative for which pathways are a foundational part of that new model. Making progress to new payment models and new quality metrics and initiatives was part of our expectation with this program. Three years after the inception of the Cancer Care Quality Program, Elevance Health established a practice engagement team where oncology nurses and pharmacists are deployed across the U.S. to work with individual practices in a collaborative fashion. These relationships have taken root and have allowed us to seamlessly launch the Oncology Medical Home in many markets across the U.S. in a variety of different practice settings.”

Indications in program have broadened

Another way in which the program has changed is that when it started, it was focused on pathways for breast, lung and colorectal cancer. But now, “there are now more than 20 cancers included and more than 80 common clinical scenarios for cancer treatment and more than 300 separated clinical pathways,” says Michael Fisch, M.D., national medical director for oncology at Carelon Insights.

The high level of oncologist participation observed in the study continues to be seen today, says DeBono. “This is a program that is generally well-received, has limited administrative burden to practices and has now generated positive quality outcomes.”

So what are important takeaways from the study for payers considering a similar program?

“First, understanding the clinical scenarios being treated and the full drug and supportive care regimens being prescribed sets the stage for comparing treatment patterns with current evidence and guidelines,” says DeBono. “A common phrase in medicine is that ‘you can only manage what you measure,’ and knowing these details allows payers to have a transparent discussion about optimal, evidence-based prescribing. In addition, knowing these fundamental data allows payers to plan for the future as new drugs and therapies emerge and new opportunities for alternate payment models and new collaborative relationships evolve.

Program was first step in shift to value

“This program was meant to be a first step in an evolution to value-based strategies in oncology,” he continues. “It was our intention to encourage practices to begin assessing their treatment decisions through a value lens. We understood that shifting toward a value-based environment would involve practice transformation, and the enhanced reimbursement part of the program was designed to support care coordination and treatment planning, as well as practice efforts to transform their practice patterns to reflect this movement toward quality and value.”

According to DeBono, “just as drug development is based on sound concepts, pilot data and bio-plausible ideas, so are payer programs. But the same way that new drugs must be studied, novel payer programs need to be evaluated objectively. This type of collaboration between Elevance Health, its subsidiary companies Carelon Research and Carelon Insights, and the University of Pennsylvania shows how such a research partnership can work. In this case, the evaluation showed a favorable effect of the program, but that finding could have been different, and Elevance Health was committed to publishing the results to share with the larger oncology community, regardless of the results.”

Model prompted oncology medical home

One of the new models that evolved from CCQP is Elevance Health’s oncology medical home, which started this past July with large oncology practices in California, Colorado, Connecticut, Ohio and Virginia for members with employer-sponsored plans in those states. The insurer expects more practices in those states, as well as others, to join in early 2021. Pathway adherence, avoided hospital admissions and emergency department visits, and appropriate antiemetic use are the current quality indicators.

In an interview with the American Journal of Managed Care, DeBono said the oncology medical home is aligned with the American Society of Clinical Oncology’s (ASCO) Patient-Centered Oncology Payment model, which is focused on four components.

The first component is practice delivery requirements, which Elevance Health refers to as core competencies. “These are the type of care processes and comprehensive care that must be available to our members who are receiving oncology care, either within an oncology practice or a cancer center,” he explained. The second aspect is participation in a pathways program. Elevance Health, he said, believes that its program “is encouraging value-based strategies in oncology and ensuring high-quality care for our members.”

The other two components are tied to financial incentives for practices: a monthly care coordination fee and incentives for quality care and metrics. On the first aspect, the insurer designed the fee to be ascribed to members undergoing outpatient chemotherapy or immunotherapy. “We believe that the monthly care coordination fee will help support the practice, as they transform their care from a fee-for-service environment to a value-based environment,” stated DeBono.

On the last component, Elevance Health has incentives for practices that improve quality metrics and outcomes. According to DeBono, “we believe that encouraging the improvement of these quality metrics will move the oncology practice toward a higher-value care, without compromising on the exciting modern therapies of precision medicine in oncology.”

Contact Bekelman through Steve Graff at stephen.graff@pennmedicine.upenn.edu and DeBono via Leslie Porras at leslie.porras@elevancehealth.com.