Employers: Innovators and Partners in the Delivery of More Effective and Equitable Cancer Care

https://doi.org/10.37765/ajmc.2020.88559

The human impact of cancer is staggering. The American Cancer Society (ACS) estimates that in 2019, 1,762,450 individuals received a diagnosis of cancer, with the number of cancer deaths projected to exceed 606,000.¹ The good news for patients and families, however, is that we are living in the midst of a period of extraordinary innovation in oncology.²

More importantly, the pace of integration of new diagnostic, risk stratification, and therapeutic knowledge is translating into improved survival outcomes. A 2020 ACS report found that the “death rate from cancer in the US declined by 29% from 1991 to 2017, including a 2.2% drop from 2016 to 2017, the largest single-year drop ever recorded.”³

Stunningly, some of the most dramatic gains in cancer survival rates have occurred among patients with certain cancer types, such as metastatic non–small cell lung cancer (NSCLC), for which survival outcomes were poor historically. At this time, however, our abilities to effectively deliver these extraordinary advances are challenged by the rapidly escalating costs of care, continued disparities in cancer survival outcomes, and care payment and deliver systems that erect barriers for patients and families trying to access the care they need.

Rising costs are a significant challenge to the financial sustainability of health care payers, including state and local governments, private health plans, and employers. One major success story in cancer care has been the rapid pace of development of novel, innovative anticancer therapeutics and immuno-oncological agents. Authors of the IQVIA report, “Global Oncology Trends 2019,” note that between 2016 and 2018 the number of patients who were treated with immuno-oncologic treatments doubled to over 200,000 patients in 2018.2 Additionally, they write:

The pipeline of drugs in late-stage development expanded 19% in 2018 alone, and 63% since 2013. Within the pipeline, across all phases of clinical development, the most intense activity is focused on nearly 450 immunotherapies with more than 60 different mechanisms of action. Ninety-eight next-generation biotherapeutics—defined as cell, gene and nucleotide therapies—are also under clinical investigation and leverage 18 different approaches. The combined immunotherapies and next-generation biotherapeutics are targeting almost all cancer tumor types with over 80 mechanisms of action.2

The IQVIA authors, however, make the sobering observation that in 2018 the average cost of a new oncology drug was $140,000, with new drug costs potentially exceeding $300,000 annually.2 Moreover, a survey of Medicare Part B oncology drug pricing, the pricing of 24 index anti-cancer drugs rose an average of 25% between 1996 and 2012 (18% after adjustments for inflation), even after generic drugs became available.⁴

Another contributing factor to higher, nonvalued added health care costs is the impact of low-value care delivery. This includes the issue of interclinician variability in treatments for patients. A 2019 analysis of CMS/Medicare data for claims related to 3,159,834 Medicare beneficiaries found that physician practice may contribute substantially to the delivery of low value care.⁵ While this CMS data analysis was performed for patients receiving care in from generalist physicians, the issue is also present in the domain of cancer care. In an analysis of 5651 women with stage breast cancer with secondary metastatic disease, nearly 1 in 5 received care that was not concordant with treatment guidelines adopted by the National Comprehensive Cancer Network. “Nonconcordant treatment was associated with higher health care utilization and costs, with mortality differences observed by the type of guideline deviation.”⁶

Enormous disparities exist in the cancer care domain, with many patients, including those from historically underserved minority communities, have worse cancer survival outcomes and a lower likelihood to receive such care advances equitably.⁷ Moreover, significant disparities in clinical outcomes are also evident. These include disparities for patients from underrepresented minorities, patients in rural and underserved areas, and members of the LGBTQ population. Patients who are beneficiaries of state Medicaid programs may also have particularly poor cancer care outcomes.⁸

In response to escalating drug and care costs for oncology patients, many commercial, government, and private payers have focused upon lowering the inflation rate in cancer care costs by applying the same tools that they have used with varying degrees of success in primary care. The Institute for Healthcare Improvement Triple Aim of Care model proposes that population health can be delivered more effectively and in a more patient-centered way while, in the process, provide for care that is delivered at a lower per-capita cost.⁹ The “Triple Aim” is meant to drive increasingly effective, efficient, equitable care, but in cancer care, it is a blunt instrument. Failing to account for challenges that are specific to cancer can drive false choices and a fatal misalignment between value-based reimbursement and care delivery. Narrow networks and limited provider networks may contain costs in primary care, but in cancer care, they may block access to disease-specific care expertise, which may raise the risk of disparate survival outcomes. It is worth noting that the doubling time for new knowledge in the cancer domain is less than 3.5 years.¹⁰ Systems focused on cost and simplistic models of value—that fail to account for survival and patient experience—frequently fall short in valuing innovation and the importance of survival outcomes. The drive to lower costs does not, by necessity, lead to better care decision-making nor does it lead to more equitable access to the fundamental knowledge needed to effectively wield the rapidly growing armamentarium of anticancer therapeutics. Avoidance of, or delay in, the use of newer, more effective targeted therapies may reduce short term expense, but does not optimize a patient’s chance of survival. This approach may not achieve long term cost savings when taking into account total lifetime cost and productivity.

Simple solutions far too often culminate in simplistic systems that over promise and underdeliver. In places like California, the delegated risk model demonstrates how well-intentioned attempts to place accountability for cost and use upon clinicians can actually result in less efficacious, less equitable care that undermines the effectiveness of care in the cancer domain. Much of the focus upon increasing cost efficiency in care, including cancer care, has been placed upon shifting risk from payers toward those delivering care. When care expertise and the knowledge base from which care is delivered is relatively stable, frequency of disease is high to allow risk amortization and predictability, and the year over year cost of therapeutics are consistent with inflation, this can be achieved by leveraging care pathways, guidelines, nurse-based support systems, and patient engagement strategies that do not require continuing evolving treatment strategies. This same care model, when applied to the cancer care domain, however, is likely to result in less effective care, less patient-tailored care delivery, and less effective integration of new knowledge into the care delivery model.

In a world where death rates from cancer vary by ZIP code and distance from an National Cancer Institute-designated or academic center, there is little evidence that the traditional levers of the population health model are producing the best outcomes or reducing disparities in cancer care. Disease management, case management, narrow networks and Centers of Excellent (COH) for cancer have been in place for over 25 years. Yet, while the science continues to evolve, disparities in health care based on race and geography persist; enrollment in clinical research trials remains at 4% for all patients, and lower for minorities; practice and institution-specific survival rates for cancer are not transparent to patients and families and are largely invisible to even the most engaged of consumers; and there is ample evidence that genomic testing to guide selection of targeted therapy is poorly or underused.^11,12

The Role for Employers

While many wait for CMS to clarify its reimbursement and care delivery policies, employers are currently taking an active, innovative role in improving patient access, care effectiveness, patient experience, and more sustainably managing health care costs and value for their respective member populations.¹³ It is hard to overstate the impact of American employers upon patient access to care and health care coverage. As of 2019, 68% of Americans had private insurance coverage; 55.4% of the American population received their health care coverage through employer-provided health care coverage.¹⁴ Their role as guarantors of patient access to health care comes at a significant cost. In 2020, the average annual employer contribution per employee (not including the portion paid by the employee) “was $7188 for single coverage and $20,576 for family coverage.”¹⁵ More startling, the Kaiser Family Foundation finds that, “the average premium for employer-sponsored family health coverage increased 22% over the [past] 5 years and 54% over the last 10 years.”¹⁶

Employers may provide health care benefits to their members (representing their employees, family members, and defined beneficiaries) through 2 models.¹⁷ Under a fully insured model, employers pay a monthly fee to a health plan that assumes subsequent financial risk for the care of the population. At the end of the year, there is no opportunity for the employer to receive money back should the aggregate health care expenditures for the population prove to be less than the sum of the premiums as part of their expenditure management strategy, many employers have moved toward a self-funding model. Under this strategy, the employer assumes the financial risk for the costs of health care delivery to their population, while contracting with a third-party administrator to administer their health care benefits. Self-funding is a model that may be more suitable for larger employers for whom creation of a trust fund financial pool may be more feasible. As part of their financial management strategy, self-funded employers may purchase re-insurance for stop-loss coverage for high cost outliers. Employers who choose the self-funded model may also be exempt from some federal and state regulations related to plan design. Such employers need to develop a summary plan description that details covered services and member benefits. In an article for the Business Benefits Group, Brandon Downs noted the 4 key benefits of the employer self-funded model: (1) Cost savings from benefit design changes; (2) increased flexibility and control of the plan; (3) Enhanced flow of cash, and (4) Cost savings from reduced premiums.¹⁸

Among the breadth of health care issues encountered by employers, cancer care represents a particularly important area of focus. Inasmuch as health care costs continue to rise at significant pace, rising cancer care costs represent a significant challenge for many employers. Moreover, authors of an NEBG presentation noted that, “Employers report a level of complexity in managing employees’ cancer-related needs beyond that associated with any other type of disease or condition.”¹⁹ The authors further note that although cancer care accounts for only 1% of their health care claims, this consumes 12% of more of their annual health care expenditures.19 Employers therefore face a series of significant challenges related to cancer care including those of equitable care delivery to their members, the financial sustainability of their model, and ensuring that their expenditures are not wasted in the delivery of low value care.

Employers have embraced an innovation mindset in meeting the challenge of cancer care. While definitions by government payers of what constitutes value-centric care focuses primarily upon health care costs or relative weak process-based metrics of assessing care quality, employers are able to focus upon factors, that include a much more expansive view of patient outcomes, the quality of patient experience (including patient and family input on the human experience of the care), duration of disability, and long-term costs associated with care (rather than just the short-term transactional costs of care). Using the flexibility afforded under the self-funded model, employers have creatively explored benefit design to ensure for more effective, equitable, and financially sustainable care for the beneficiaries.¹⁹

This innovation mindset has taken a number of directions. Some employers have begun direct contracting with academic cancer centers to provide services to their employees and members. These include General Electric, Boeing, Walmart, and Lowe’s all of which have used this model to reduce costs, improve quality, and to carefully define a patient experience so that care delivery model.²⁰ Part of the benefit of this direct contracting model, is that it allows for more transparent tracking of patient experience and outcomes that may be achieved through a standard care payment model. One example of such a program is Walmart’s collaborative Centers of Excellence Program that includes a partnership with Mayo Clinic in the care of patients with certain cancer types, joint replacement, spine care, and transplant services.²¹

In line with this model, a number of employers have partnered with the Pacific Business Group on Health (PBGH) to deliver more transparent, effective, and more patient-centric care through the Employers Centers of Excellence Network (ECEN). On January 1, 2019, ECEN expanded their care models to include cancer care. City of Hope Comprehensive Cancer Center was the first center included in the program.²² The ECEN model aims to provide a robust care ecosystem where employer members can immediately access advanced care expertise that is delivered in a manner that includes interdisciplinary care collaboration, psychosocial care needs assessments and support, and behavior health care and support. Under this offering patients may benefit from clinical expertise in supportive/palliative care medicine, cancer genetics, genomic diagnostics, and survivorship that is delivered through a unique patient and family centric care model. For the employer, this addresses the needs to ensure that transformative care expertise is made easily available to patients and families, that patients may be screen for relevant clinical trials in a robust and consistent manner, and that care is delivered in a way that minimizes burdens to patients and their families.

Yet, the center of excellence model does have a number of limitations, not the least of this is that for many patients extended travel away from their home is not a sustainable model for receiving cancer care. In reality, approximately 55% of patients with cancer in the United States receive their cancer care in the community practice setting.²³ As such, developing more effective decision support tools for community clinical, assistance in identifying relevant clinical trials for patients at high risk or those for whom the existing standard of care may be ineffective or unsuitable to a particular patient, and assistance in supporting clinicians in the interpretation and clinical decision-making related to the interpretations of genomic and molecular testing results.

Employer innovation has also involved pushing the boundaries of knowledge access and disease-expertise access. AccessHope is a subsidiary of City of Hope that is working within this innovation space.²⁴ A key part of the model for AccessHope is the belief that transformational clinical knowledge is exportable even across geographic barriers in which the capacities of “bricks and mortar” care represent a challenge to patient access to essential care (See related cover story). At present, AccessHope is working with more that 34 employers that represent 2 million covered lives through models that are geared toward forming supportive, collaborative relationships with local clinicians that is focused upon keeping patients closer to home, with their community-based clinician.

Through multiple innovation models, employers are beginning to have a significant impact upon cancer care access and care delivery. Part of their engagement strategy includes a clear value proposition for what they seek from cancer care experts and cancer centers. This includes the expectation that high complexity care is delivered in increasingly patient-centric ways that enhance timely patient access to transformation care knowledge. It also includes higher demands for significantly more transparent reporting of cancer care outcomes. In addition, as employers work with cancer care delivery thought leaders and centers of expertise, it will be feasible for multidisciplinary team of clinicians, health care plan executives, patients and the employers’ internal health care benefits leadership to define the rights of all patients with cancer and define a list of critical or complex cancer conditions or situations for which the patients would be allowed to seek expertise beyond their HMO, medical group or accountable care organization and how their internal cancer care ecosystem can be enhanced to ensure that all patients, regardless of wherever they live, have the opportunity to benefit from the full breadth of cancer care innovations.

Employers have the focus, innovative mindset, analytical tools, and drive to partner effectively with innovative cancer care entities to bring better care to their respective members. Under the balanced model of wanting better, more innovative care made available in ways that reflect best practice and knowledge-driven stewardship over the rapidly growing portfolio of anticancer therapeutics, employers and their clinical partners are best positioned to define best in class access, care, and patent-center models for cancer care.

References

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2. Nass D, Simorellis A. Global Trends in Oncology 2019: Therapeutics, Clinical Development And Health System Implications. IQVIA Institute for Human Data Science. Published May 30, 2019. Accessed December 3, 2020. https://www.iqvia.com/insights/the-iqvia-institute/reports/global-oncology-trends-2019

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14. Berchick ER, Barnett JC, Upton RD. Health Insurance Coverage in the United States: 2018. United States Census Bureau. Report number P60-267 (RV). Published November 8, 2018. Accessed December 3, 2020. https://www.census.gov/library/publications/2019/demo/p60-267.html

15. eHealth. Average cost of employer-sponsored health insurance. Updated November 23, 2020. Accessed December 3, 2020. https://www.ehealthinsurance.com/resources/small-business/average-cost-of-employer-sponsored-health-insurance

16. Claxton G, Rae M, Young G, et al. Employer Health Benefits Annual Survey 2020. Kaiser Family Foundation Published October 8, 2020.Accessed December 3, 2020. http://files.kff.org/attachment/Report-Employer-Health-Benefits-2020-Annual-Survey.pdf

17. WMI TPA. Self Funding 101. Accessed December 3, 2020. https://www.wmimutual.com/publications/presentations/Self-Funding_101_(9-17).pdf

18. Downs B. Top 4 reasons employers are switching to self funding insurance. Business Benefits Group.. Published August 17, 2018. Accessed December 3, 2020. https://www.bbgbroker.com/self-fundinginsurance-switch-4-reasons/

19. Nobel J, Pickering L, Sasser E. Employers and Cancer Care Quality: A Closer Look. North Eastern Business Group on Health. Published April2016. Accessed December 3, 2020. https://nebgh.org/wp-content/uploads/2016/04/NEBGH_CancerRoundtable-FINAL-flat.pdf

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21. Mayo Clinic. Walmart Centers of Excellence Model. Accessed December 3, 2020. https://www.mayoclinic.org/centers-of-excellence/walmart

22. Pacific Business on Health. The Employers Centers of Excellence Network expanding to include ‘best of both’ cancer care. Accessed December 3, 2020. https://www.pbgh.org/news-and-publications/pbgh-in-the-news/491-the-employers-centers-of-excellence-networkexpanding-to-include-best-of-both-cancer-care

23. Community Oncology Alliance (COA). Fact sheet: what is community oncology? COA. Published 2017. December 3, 2020. https://communityoncology.org/wp-content/uploads/2017/08/What-is-Comm-Onc.pdf

24. AccessHope. Accessed December 3, 2020. https://www.myaccesshope.org