Commercial Health Plans: Operational Objectives in Oncology Management and Market Access Metrics

Commercial Health Plans: Operational Objectives in Oncology Management and Market Access Metrics

Highlights of the report:
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As new oncology therapies enter the market and prices continue to rise, commercial health plans strive to ensure use of the most cost-effective, appropriate treatments for patients. HIRC's report, Commercial Health Plans: Operational Objectives in Oncology Management and Market Access Metrics, reviews commercial plans' approaches to oncology management and examines the resulting market access landscape across ten cancer types. The report addresses the following:

  • Which operational objectives drive health plan decision-making in oncology medication management?
  • What is the status of payers' utilization management tactics for oncology medications across benefits?
  • What is the status of oncology clinical pathway adoption and development across ten cancer types?
  • What is the rationale for selecting oral and IV oncology medications? What are the methods used to promote preferred products across ten cancer types?

Key Finding: On average, commercial health plan respondents report investing the most resources to actively engage and collaborate with organized providers on initiatives to better manage cancer care.

Payers Report Appropriate Utilization as the Top Concern Related to Managing Member Access to Oncology Medications. Commercial pharmacy and medical directors were asked to provide the plan's single biggest concern when it comes to managing member access to oncology medications. Payer's report an increasing concern for appropriate utilization and use of evidence-based medicine year-over-year. Additional primary concerns include cost of medications and care coordination.

The full report provides a complete list of plans' top concerns in managing member access to oncology medications, affordability of care in oncology, and optimizing outcomes.

Notable Differences in UM Tactics to Manage Oncology Medications Across Benefits Emerge by Plan Type. Respondents were asked to indicate whether the plan has numerous utilization management tactics in-place to manage oncology medications across benefits. Respondents from all plan types report using PA clinical criteria to cover the entire therapy across benefits, however respondents from national and regional plans report utilizing tactics such as directing patients to cost-effective sites for care for infusions as well as switching physician reimbursement to ASP+ more often than BCBS plans.

The Number of Health Plans Reporting Preferred Oncology Products in Renal Cell Carcinoma Remains Low. Only nine commercial health plan panelists report designating at least one oral medication as having preferred status in RCC, and only two panelists report designating at least one IV medication as preferred in RCC. Though preferred status of oral oncology medications in RCC are uncommon, panelists most often report preferring Sutent, Afinitor, and Nexavar.

Research Methodology and Report Availability. In March, HIRC surveyed 53 pharmacy and medical directors from national, regional, and BCBS plans representing 84 million lives. Online surveys and follow-up telephone interviews were used to gather information. The complete report, Commercial Health Plans: Operational Objectives in Oncology Management and Market Access, is available now to HIRC’s Managed Oncology subscribers at www.hirc.com.

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