Current Trends in Oncology Managementfiles.ctctcdn.com/b40a8491101/2860bbf2-d897-4aad-a466-d... · 2015-08-22 · Third Edition –January, 2013 3 •Research Objectives •Understand

Current Trends in

Oncology Management

This Current Trends in Oncology Management report was derived from an independent study undertaken by The Zitter Group, a

managed care consulting firm specializing in market research

ON82332 01/2013 Lilly USA, LLC

2 Third Edition – January, 2013

Overview

End-of-Life Care

Prior Authorizations

Reimbursement Dynamics

Outline


• Research Objectives • Understand selected changes underway in oncology and payer management of the category

• Examine possible implications for payers, oncology practices, and manufacturers

• Highlight views and opinions about the managed care and oncology practice environments

• Research Methodology • An independent study undertaken semiannually by The Zitter Group, a managed care consulting firm

that specializes in market research

• The Zitter Group’s study in oncology has been conducted since December 2006

• The research entails concurrent Web-based quantitative surveys with 3 arms: managed care executives (payers), oncologists, and practice managers

– Payer sample comprised of 101 managed care decision makers from large national and important regional

and independent health plans representing 154.3 million covered lives

– Oncologist sample comprised of 100 oncologists from a variety of practice groups across the country

– Practice manager sample comprised of 100 managers from a variety of practice groups across the country

• The study asked survey participants to respond to questions regarding their commercial business only

• Research was fielded between January 6, 2012, and February 29, 2012

• Standard statistical methods were applied to evaluate differences among stakeholder groups and between current and prior survey data

Managed Care Oncology Index: Overview


Overview

End-of-Life Care



Outline


Does your organization provide coverage for hospice care?

Hospice Care Coverage

At what point in disease progression does your organization provide coverage for hospice care?

Patient must have ______ months or fewer to live, should the disease run its expected course

Payers n = 101

Mean (of those with a time limit) = 5.6 months

Yes 90%

No 4%

Unsure 6%

Percentage of Payers

Months % Payers Number of Payers

6 56% 42 respondents

3 3% 2 respondents

2 3% 2 respondents

1 1% 1 respondent

No limit 37% 28 respondents

Unsure NA 16 respondents


Payer Communication of Hospice Care

What types of communication efforts does your organization make to educate patients about hospice as an end-of-life care option? Please select all that apply

A communication effort implies any manner by which you convey information to the intended audience, eg, print, electronic, telephone, etc.

9%

10%

13%

18%

38%

48% Physician communication efforts

Patient-specific, targeted communication efforts

Not applicable, we do not make any communication efforts

Other

Communication efforts to members of targeted demographics (eg, all members

over 65), but not to specific patients

Unsure


Payers n = 91

Payer “Other" Responses: Case Managers (8); We will respond to member requests for information or guidance, but do not initiate; Hospice included in cancer info kit now sent out regularly; Developing program to increase capacity to deliver


Physicians and patients often define "successful

treatment" differently

Payers

Oncologists

Practice Managers

Increasing hospice utilization would be an

effective way to manage oncology costs

Payers

Oncologists

Practice Managers

Hospice is most effective when the patient is

enrolled for an extended period of time (more than

3 weeks)

Payers

Oncologists

Practice Managers

16%

17%

8%

18%

7%

10%

66%

69%

66%

62%

70%

91%

80%

76%

91%

Hospice / End-of-Life Care: Stakeholder Comparison

Please tell us whether you strongly disagree, somewhat disagree, are neutral, somewhat agree, or strongly agree with each of the statements below

Somewhat disagree or Strongly disagree Somewhat agree or Strongly agree Mean

4.39*^

3.88*

4.12^

4.35*^

3.86*

3.65^

3.93

3.88

3.88

Payers n = 101 Oncologists n = 100 Practice Managers n = 100

*^ Significant difference between stakeholders

Percentage of Respondents

1%

3%

3%



Physicians view hospice utilization as a

failure or defeat

Payers

Oncologists

Practice Managers

There are significant barriers to increasing

hospice utilization

Payers

Oncologists

Practice Managers

Hospice / end-of-life programs are utilized at

appropriate levels

Payers

Oncologists

Practice Managers 50%

57%

75%

27%

30%

29%

60%

39%

22%

42%

31%

17%

44%

49%

50%

29%

38%

56% 3.37*^ #

2.86*^ #

2.50*^ #

3.25

3.14

3.20

2.11*^

2.66*

2.84^


*^ # Significant difference between stakeholders


Somewhat disagree or Strongly disagree Somewhat agree or Strongly agree Mean

Hospice / End-of-Life Care: Stakeholder Comparison


Hospice / End-of-Life Care: Payer Trend

Yes, 41% of Practice

Managers

No, 50%

Yes, 41% of Practice

Managers

No, 50%

2.25

3.55

3.41

3.80

3.87

4.24

2.11

3.25

3.37

3.93

4.35

4.39

Winter 2012

Summer 2008

Physicians and patients often define "successful treatment" differently

Increasing hospice utilization would be an effective way to manage oncology costs

Hospice is most effective when the patient is enrolled for an extended period of time (more than 3 weeks)

Physicians view hospice utilization as a failure or defeat

There are significant barriers to increasing hospice utilization

Hospice / end-of-life programs are utilized at appropriate levels

1 Strongly disagree

3 5 Strongly agree Mean Respondent Score

Winter 2012 n = 101 Summer 2008 n = 103



Hospice End-of-Life Care Refusal

What are the potential reasons for underutilization of hospice care? Please select all that apply

Asked only of respondents who Strongly disagreed or Somewhat disagreed that hospice programs are utilized at appropriate levels

2%*

2%

32%^

14%

16%^

86%

78%

11%

0%

40%*

18%

33%*^

91%

74%*

18%*

0%

7%*^

13%

18%*

88%

89%*

Payers n = 76

Oncologists n = 57

Practice Managers n = 50

Physician reluctance

Patient refusal

Limited availability / patient access

Poor quality of hospice care

Lack of payer coverage

There is no underutilization of hospice care, only overutilization

Other

Payer “Other” Responses: family issues (6); lack of physician education to patients (2); ignorance of true benefits (1); misunderstanding the role of hospice (1); negative perceptions of hospice care (1); payment associated with it is much less than chemotherapy (1); physician comfort in having the conversation is the biggest issue (1); patients feel that they will be provided with no therapy (1); Oncologists “Other” Responses: family issues (2); hospice no longer hospice (1); need for palliative procedures (1); profit motive to continue treatment (1); when a patient signs up for hospice, lose oncologists and physicians (1)

Percentage of Respondents *^ Significant difference between stakeholders


Drivers of Excess Cost: Stakeholder Comparison

What percentage of excess cost in oncology care does each of the following factors contribute? Please consider excess cost in terms of the entire care delivery system (systemic costs), not

just in terms of costs at your own organization

1%

28%*^ #

17%

6%

8%

13%

9%

17%*

3%

15%*^ #

17%

4%

7%

9%

15%

30%

0%

5%*^ #

8%

8%

12%

13%

20%

35%*

Payers

Oncologists

Practice Managers

Excessive therapeutic end-of-life treatment

Inappropriate drug utilization (eg, off-label, off-pathway, or off-guideline use)

Sub-optimal distribution of prescription drugs (eg, buy-and-bill versus specialty pharmacy)

Sub-optimal selection of sites-of-care

Excessive physician payments (for professional services only, independent of drug reimbursement)

Excessive diagnostic testing

Utilization management administrative requirements (eg, those for prior authorization)

Other


Percentage of Excess Cost *^ # Significant difference between stakeholders


Summary of Findings: End-of-Life Care

• Most payers provide for end-of-life coverage, with payers divided between capping care for patients with less than 6 months to live and payer organizations having no stipulations tied to life expectancy

• All 3 stakeholders agree that “increasing hospice utilization would be an

effective way to manage oncology costs.” Payers are significantly more supportive of the statement than oncologists and practice managers

• Payers believe strongly that hospice/end-of-life programs are not being utilized at sufficient levels

• All stakeholders view “excessive therapeutic end-of-life treatment” as a major driver of excess cost


Overview

End-of-Life Care



Outline


Payer Therapy Management Tools Trend

Which of the following tools have been applied to manage cancer therapies?

33%

37%

42%

42%

53%

53%

77%

44%

85%

36%

40%

40%

43%

54%

65%

66%

67%

88%

Winter 2012

Winter 2011

Prior authorization

Tying drug approval to diagnostic tests / biomarkers

Compendia listing guideline requirements

Quantity limits

Specific lab or diagnostic values

Step edits

Published study requirements

Clinical treatment pathways

Required drug distribution through a third-party vendor (eg, SPP, PBM)

Significant increase from Winter 2011 report


Winter 2012 n = 101 Winter 2011 n = 103


Prior Authorization Requirements

Payers n = 79

a

Please rank in descending order the influence of each of the following factors in determining your prior authorization requirements, where 1

is the most influential

Factor Average Ranking

FDA labels 2.56

NCCN compendia listings / NCCN guidelines 2.76

State mandates 4.82

CMS coverage decisions 5.56

ASCO guidelines 5.59

Peer-reviewed scientific literature 6.26

AHFS compendia listings 7.68

AHRQ / CERTs reports 8.79

Internal oncology experts 8.88

DrugDex compendia listings 9.03

Input from network oncologists 9.15

Internally developed pathways 9.88

Externally developed pathways 10.15

Do the factors that influence your organization's determination of prior authorization requirements vary by cancer subtype?

43%

51%

6%

Unsure

No

Yes

Payers n = 34


Prior Authorization Requirements

What is typically required by commercial payers to approve coverage of the products / therapies subject to prior authorization?

2%

3%

11%

28%

43%

52%

30%

81%

2%

2%

15%

40%

50%

57%

32%

85%

0%

5%

11%

36%

49%

55%*

56%*

98%

Winter 2012 n = 85

Summer 2011 n = 100

Winter 2011 n = 103

2%

10%

13%

18%

66%

34%

52%

93%

0%

12%

13%

19%

73%

33%

68%

95%

0%

3%

17%

25%

43%

78%*

77%*

97%

Winter 2012 n = 92

Summer 2011 n = 100

Winter 2011 n = 101

Diagnosis

Specific lab or diagnostic values

Statement of medical necessity from the physician

Compendia listings/guidelines

Published studies

Genetic testing

Other

None

Percentage of Oncologists Percentage of Practice Managers

Significant increase from Summer 2011 report Significant decrease from Summer 2011 report

*Significant difference between stakeholders

Oncologist Perspective Practice Manager Perspective


Prior Authorization Frequency

How frequently do commercial payers require prior authorization for oncology therapies?

Oncologist Perspective

10% or fewer treatment requests

11% - 30% of treatment requests




More than 90% of treatment requests

Unsure

Percentage of Oncologists Percentage of Practice Managers

11%

10%

24%

15%

15%

19%*

6%

13%

17%

12%*

22%

18%

13%

5%

14%

10%*

16%*

8%

15%

29%*

7%

Winter 2012 n = 100

Summer 2011 n = 100

Winter 2011 n = 103 7%

14%

23%

24%

22%

9%*

1%

6%

19%

24%*

20%

22%

7%

2%

8%

20%*

31%*

12%

17%

10%*

2%

Winter 2012 n = 100

Summer 2011 n = 100

Winter 2011 n = 101

Significant increase from Summer 2011 report Significant decrease from Summer 2011 report

*Significant difference between stakeholders

Practice Manager Perspective


Prior Authorization Completions

How long do you think it takes your office, on average, to process a typical oncology prior authorization?

< 10 min, 0%

10 - 19 min, 5%

20 - 29 min, 15%

30 - 39 min, 26%

40 - 49 min, 20%

50 - 59 min, 0%

60 - 69 min, 23%

> 70 min, 12%

< 10 min, 0%

10 - 19 min, 19%

20 - 29 min, 24%

30 - 39 min, 21%

40 - 49 min, 7%

50 - 59 min, 0%

60 - 69 min, 13%

> 70 min, 15%

Oncologist Perspective n = 85 Mean: 56 minutes

Unsure n = 17 Summer 2011 Mean: 47 minutes

Practice Manager Perspective n = 86 Mean: 48 minutes

Unsure n = 6 Summer 2011 Mean: 41 minutes


Prior Authorization Impact on Prescribing Behavior

To what extent do prior authorizations impact prescribing behavior?

26%

38%

40%

36%

34%

31%

41%

42%

40%

31%

19%

23% 2.86

2.72

2.88

3.19

Mean

Percentage of Oncologists

No significant changes between editions Oncologists Winter 2012 n = 100 Oncologists Summer 2011 n = 100 Oncologists Winter 2011 n = 103 Oncologists Summer 2010 n = 100

Winter 2012

Summer 2011

Winter 2011

Summer 2010

No impact (1) or Limited impact Some impact (3) Meaningful impact (4) or Significant impact (5)


Summary of Findings: Prior Authorizations

• Payers most commonly utilize “prior authorizations,” “diagnostic tests or biomarkers,” and “compendia listing guideline requirements” to manage oncology costs

• The majority of practice managers report that commercial payers require prior authorizations for more than 50% of treatment requests, with little change observed relative to past years

• Forty-three percent of payers note that determination of prior authorization requirements vary by cancer subtype, with FDA labels most influential in determining prior authorization requirements

• Over the past 18 months, oncologists report a diminished impact of prior authorizations on their prescribing behavior


Overview

End-of-Life Care



Outline


Pay-for-Outcomes (P4O) Components

5%

7%

21%

29%

21%

17%

Unsure

Will not be implemented within the next 12-18 months Unlikely to be implemented within the next 12-18 months Likely to be implemented within the next 12-18 months Will be implemented within the next 12-18 months Already implemented

In which of these cancer subtypes have you implemented or will you be implementing a pay-for-outcomes (P4O) component to physician

reimbursement? Please select all that apply

83% 75%

58% 58%

33% 33% 33%

25% 25%

17% 17% 17% 17% 17% 17% 17% 17% 17% 17%

Breast Colon and Rectal

Lung Prostate

Hodgkin disease Melanoma

Non-Hodgkin lymphoma Chronic lymphocytic leukemia

Kidney (renal cell) Bladder

Chronic myeloid leukemia Endometrial

Gastrointestinal stromal tumor (GIST)

Head / Neck Liver

Multiple myeloma Ovarian

Pancreatic Thyroid Percentage of Payers

How likely is your organization to implement a pay-for-outcomes (P4O) component to your oncologists' reimbursement contracts, even if only on a trial or pilot basis?

Payers n = 100

Payers n = 12


Formation of Accountable Care Organizations

Please select the following statement that most closely represents your practice’s current plans regarding accountable care organizations (ACOs)

4%

8%

19%

21%

54%

46%

23%

25%

Summer 2011

Winter 2012

Already joined / formed an ACO Intend to join / form an ACO

Have not decided whether or not to join an ACO Do not intend to join / form an ACO

Percentage of Oncologists

Winter 2012 Oncologists n = 100 Summer 2011 Oncologists n = 100

No significant differences between editions


Practice Financial Viability: Stakeholder Comparison

Given the progression of oncology management, how would you rate the financial viability of your practice?

Please score your perception of practice viability using a 10-point scale, where 1 indicates “Not at all financially viable” and 10 indicates “Very financially viable”

5%

7%

12%

19%

8%

15%

54%

62%

45%

50%

37%

53%

53%

59%

45%

34%

53%

43%

51%

27%

40%

27%

Low viability (1-3 rating) Moderate viability (4-7 rating) High viability (8-10 rating)

Oncologists

Practice Managers

Oncologists

Practice Managers

Oncologists

Practice Managers

Practice Managers

Oncologists

Winter 2014 (est.) n = 82




Winter 2012 (actual) n = 92




5.95*

6.73*

5.99^

6.85^

6.92

7.39

6.63

7.10


*^Significant difference between stakeholders

Mean


Impact of Payer Management on Practice Consolidation

ASP 58.8% of sample

(-3.7% from Winter 2010)

66.2% of covered lives

(-4.5% from Winter 2010)

ASP 61.2% of sample

AWP 31.1% of sample

Do you believe that tighter oncology management by payers will force smaller oncology practices to consolidate into larger ones?

75%

78%

82%

85%

79%

82%

Strongly disagree (1) or Disagree (2) Believe it (4) or Strongly believe it (5)

Winter 2012 n = 100

Summer 2011 n = 100

Winter 2011 n = 103

Winter 2012 n = 100

Summer 2011 n = 100

Winter 2011 n = 101

Oncologists

Practice Managers


No significant differences between editions or stakeholders

5%

2%

5%

7%

8%

5%


Oncology Practice Consolidation: Payers

Within the past twelve months, how has the consolidation of oncology practices progressed?

A ______ number of oncology practices have consolidated in our coverage area

How has this consolidation been driven by the following stakeholders?

25% 24% 25% 8% 16%

None Minimal Moderate Significant Very Significant Unsure

2

12

12

24

50 Hospital / hospital system acquisition

Larger community oncology practices (10 or more physicians)

Smaller community oncology practices (fewer than 10 physicians)

National / regional oncology practice associations

Other

Average Points Assigned Payers n = 59

Payers n = 100


Summary of Findings: Reimbursement Dynamics

• Twelve percent of payers reported that they have implemented or will implement a pay-for-outcomes component to their oncologists’ reimbursement contracts, while half of payers state that they are unlikely or will not be implementing a pay-for-outcomes component as part of contracting in the next 12-18 months

• A majority of practice managers and oncologists believe that tighter oncology management by payers will force smaller oncology practices to consolidate into larger entities

• Over the past 12 months, nearly 60% of payers note that oncology practices have consolidated, with hospital/hospital system acquisitions being the driving force beyond consolidation

Documents

Current Trends in Oncology Managementfiles.ctctcdn.com/b40a8491101/2860bbf2-d897-4aad-a466-d... · 2015-08-22 · Third Edition –January, 2013 3 •Research Objectives •Understand