Life Sciences

Managed markets program asks payer MDs to talk business during clinical meeting

Medicare & Reimbursement Advisor Weekly, August 26, 2009

Editor’s note: A view from a health plan medical director on a difficult category was presented on a panel of health payer thought leaders last year. Highlights from this speech are featured below. Of note here is that this interview was part of a managed markets program to hold a business/reimbursement- oriented panel during a clinical society meeting (in this case, ASH). Was it like putting oranges on the McDonald’s menu? Maybe not, since attendance was more than 100 physicians, many who attended multiple sessions in the series. I was the writer. The program discussion was recorded and disseminated to private practice clinicians and administrators as part of the managed markets series. (See the full link below to access.)

Consider the cost of oncology in the payer’s terms: Anthem collects approximately $200–$300 from each commercial member per month, and a single diagnosis of cancer diagnosis takes $50–$100 of that income. “If you roll that out, we’re paying about $200 million a month for cancer,” said Jeff Kamil, MD, vice president and senior medical director at Anthem Blue Cross. “In New York, cancer care—which includes physician, hospital, radiology, and pharmacy services—may be consuming as much as 20% of medical costs. That’s a startling number for me,” Kamil said.

Historically, health plans’ approach to oncology has been to contract for the best deal, he said.

Further, Kamil added that health plans have not had the required professional or technical expertise to engage oncology care. Oncology is a complex field with many disease stages and treatment options, and like all other parts of the healthcare system, the disease has its share of overuse, underuse, and misuse of drugs.

However, health plans can no longer continue to ignore cancer, since oncology is a “trend driver” with new targeted biologics and an increased growth in spending. As a result of clear medical evidence and labeling for the newer agents, especially in regard to safety and off-label use, “cancer care spend is growing at 20% per year; so [it’s] a trend that will get attention,” Kamil said.

Addressing the future and where the cost, quality, and physician dilemma is headed, he said health plans should help oncologists provide higher-quality cancer care but use resources in a more efficient way.

To accomplish this, health plans will insist that oncology care be evidence-based and develop administrative tools to enable this (e.g., the NCCN guidelines—developed as algorithms—encompass 97% of the tumors encountered in oncology practices).

On the horizon, Anthem is working with oncologists to develop new tools and relationships that will improve health plan and oncology interfaces and relationships.

To read the full story that I wrote about this topic, go to the following link at and contact me with any questions.