Lack of Drug Information Makes it Hard to Get Payer Approvals

Published: Thursday, Aug 20, 2015
Andrew L. Pecora, MD

Andrew L. Pecora, MD

Data collection has to be improved in order for physicians to be able to convince payers to support certain types of costly therapy, a panel of physicians agreed during a wide-ranging OncLive Peer Exchange conducted at the 2015 ASCO Annual Meeting.

Payment issues, electronic health reporting, how to attract younger physicians to oncology, and the growing role of women physicians in this traditionally male-dominated profession were discussed in the Chicago forum.

Below is an edited and condensed version of the discussion, which was moderated by Andrew L. Pecora, MD, editor-in-chief of Oncology Business Management and chief innovations officer at John Theurer Cancer Center in Hackensack, NJ. Participants included Michael Kolodziej, MD, national medical director of Oncology Solutions, Aetna; and Jeffery C. Ward, MD, of Puget Sound Cancer Centers, Edmonds, Washington.

A range of oncology practice management issues were discussed in an OncLive Peer Exchange meeting held at the 2015 ASCO Annual Meeting in Chicago. Participating were Jeffrey C. Ward, MD; Andrew L. Pecora, MD; and Michael Kolodzeij, MD.

Andrew Pecora: Suppose in the advanced stages of treatment you get a positive signal that says an mTOR inhibitor might work with a patient. Of course, it’s not FDA-approved, and the payer won’t pay for it, and the patient can’t afford to pay for it. What do you do?

Michael Kolodziej: I think the big challenge for payers is trying to sort out what’s legitimate and what’s not. The question is, how do we get payers to say “Yes”? If we could develop a methodology by which we actually collected information about these one-offs, we would not only improve care for all patients with cancer, but we would make the no-yes dichotomy a heck of a lot easier for payers.

Jeffery Ward: I think that you explain that this is a very rare case, and you’ve done this test and it demonstrates that it may work. And insurers say, “Yes, we will pay for it as long as that data gets into a registry—that we learn from it.” You know that 97 percent of the care that we give, we learn nothing as far as outcomes.

Michael Kolodzeij, MD

Michael Kolodzeij, MD

AP: How do you view the rapid movement toward personalized medicine— the use of genomic testing, and the new and expensive medications such as checkpoint inhibitors?

MK: Now, we’re restricting care really to patients who have either a high risk of systemic disease or have systemic disease, and they are clearly the single most expensive group of patients. The general thinking is that we would like to make sure that the right patient gets the right treatment at the right time. What I think is not necessarily a path forward is unbridled enthusiasm and, “If it works in this, it must work in that.” I’ve heard it more than once: “I’m an oncologic chef.” Those days are over. You had better be a good oncologic short-order cook, because we depend on you to make that hamburger right. But an oncologic chef where you decide you’re going to try a little bit of ingredient A and ingredient B is probably an unsustainable approach going forward.

AP: What about disparities in cancer care?

JW: I think disparities are predominantly created by access. The barriers to access can include socioeconomic barriers, and language barriers when we’re talking about immigrant populations, and then cultural issues. There are some issues with trust with the medical establishment. I think if you remove those barriers and patients have access, you’re going to see most of those disparities go away.

AP: How should we think about and address the comorbidities and behaviors that lead to cancer?

MK: This probably is the primary intent of the quality metrics which have been widely criticized—for example, Administration for Community Living (ACL) program in Medicare. The idea that we can improve population health with the ACL—making sure that people get their mammograms, have colonoscopy, have their A1Cs checked, don’t use cigarettes, and monitor their weight—is population health management. This is not really an oncologist issue. This is an issue for primary care.

AP: How do we encourage more young physicians to enter the oncology field?

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