WellPoint Offers Oncologists Incentives to Follow Pathways

Roxanne Nelson

June 12, 2014

Will giving oncologists financial incentives to "stay on track" help reign in cancer costs?

At least one insurer, and maybe more in the future, are counting on it. WellPoint, one of the largest health benefits companies in the United States, will begin offering oncologists a monetary incentive for each patient who receives treatment for breast, colorectal, and lung cancer, as specified by one of the insurer's recommended regimens.

The program will begin on July 1, and initially be rolled out in Indiana, Kentucky, Missouri, Ohio, Wisconsin, and Georgia, but is expected to expand to other states throughout this year and into 2015. It will be applicable to fully insured and self-insured members, those with Medicare Advantage, and national account members who live in states in which the program has been initiated.

"This program — while sharing best practices and evidence-based medicine — also helps to support oncologists who require large staffs to treat these complex patients and provides the practice with enhanced reimbursement to offset the lower fees they receive when prescribing less expensive drugs," commented Jennifer Malin, MD, PhD, WellPoint oncology medical director, in a statement.

The WellPoint Cancer Care Quality Program was developed in collaboration with WellPoint subsidiary AIM Specialty Health, and identifies certain cancer treatment pathways that were selected based upon current medical evidence, peer-reviewed published literature, consensus guidelines, and WellPoint's clinical policies. The premise is to support oncologists in identifying cancer treatment therapies that are highly effective and provide greater value.

According to WellPoint spokesperson Lori McLaughlin, if a practice follows the pathways, it will receive a $350 one-time fee at the onset of treatment planning and care coordination.

"The practice will also receive $350 per month per patient while the patient is active in therapy and on pathway," she said. "This should offset on average the difference in what the practice makes from administering more costly drugs, they say. The goal is that the Cancer Care Quality Program is revenue neutral for the practices, but encourages them to follow the best evidence."

Pathways Already in Use

The idea of clinical pathways to guide care is certainly not new, and some data suggest that they can help reduce cost without compromising the quality of care. One study published last year found that an oncology pathways program could save about 15% on cancer-related costs and reduce hospital admissions by about 7%.

As previously reported by Medscape Medical News, this scheme was devised by Cardinal Health, a Fortune 500 healthcare services company that specializes in the distribution of pharmaceuticals and medical products. In partnership with payers, they established evidence-based oncology treatment pathways to eliminate unnecessary medical interventions and promote the most cost-effective treatments to enhance care and reduce costs. In August 2008, Cardinal Health Specialty Solutions partnered with CareFirst BlueCross BlueShield to launch the first cancer clinical pathway in the United States.

"Only recently have we had enough experience, analysis, and data to subject our work to validation and peer review," said Bruce Feinberg, MD, chief medical officer of oncology at Cardinal Health Specialty Solutions, at the time the study was reported.

The Centers for Medicare & Medicaid Services are currently reviewing a proposal from a major consulting company to use oncology clinical pathways in a pilot program designed to control costs and promote more uniform medical practice. The US Oncology Network, a nationwide network with approximately 1000 oncologists, has also developed its own clinical pathways. They have partnered with insurers to use preferred treatment pathways for adjuvant and metastatic regimens in breast, lung, and colorectal cancers.

Patient by Patient

The WellPoint guidelines currently cover breast, colorectal, and nonsmall-cell lung cancer, and WellPoint notes that the pathways are not available for every patient's medical condition but are intended to be applicable for 80% to 90% of patients. According to a document outlining the pathways, "given the complexity of cancer and all of the unique individual circumstances, it would not be possible to have a Pathway for every specific situation. The treating oncologist will determine if, in his/her medical opinion, a Pathway treatment is the best option for a patient or whether, given his or her unique circumstances, another treatment regimen will be a better treatment for him or her."

In an article published in the Wall Street Journal , Richard Schilsky, MD, chief medical officer of the American Society of Clinical Oncology, was quoted as saying that the WellPoint program contains "many of the important elements you'd like to see" in a pathways initiative. However, he also pointed out that this type of program can drive everyone toward getting the same treatment, while "precision medicine wants to drive toward everyone getting unique treatment."

Also reported in the same article, Brian J. Bolwell, MD, chairman of the Cleveland Clinic's Taussig Cancer Institute, said that his institution will participate in the WellPoint program "where it makes sense," and the extra $350 payment "is not something we'd ignore."

Dr. Bolwell said that WellPoint's clinical recommendations were reasonable, but that they were also developing their own treatment pathways, and according to the article, he was also "concerned about facing different recommendations from each insurer."

"We generally don't like to practice by insurance company. We practice by patient," he said.

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