Cancer Patients Can Better Manage Care with Early Support from Payers

When patients are first diagnosed with cancer, they face many difficult decisions at a time when they are extremely vulnerable. Payers, recognizing that these patients are scared, have myriad questions about their situation and need prompt and appropriate support, can be in an excellent position to communicate effectively with their members about their cancer care.

The benefits for early payer contact with cancer patients are two-fold: members get immediate information about their disease and its treatment to help them navigate the health care system, and payers may find that their members experience fewer unnecessary or inappropriate treatments, have improved outcomes and incur lower treatment costs, according to Marybeth Regan, Ph.D, global managing partner for Reden & Anders, an Ingenix company.

“The gut response of a patient just diagnosed with cancer is to go into this black hole where the dominant question is ‘Am I going to die?’ so it is hard for any other information to get through at that moment,” Regan said. “After the diagnosis sinks in a bit, the patient has to make decisions quickly and wants to know how he or she is going to find a provider, and what modes of treatment, among the many available, are most appropriate for him or her.”

Changing market supports new approach

As a result of the Health Insurance Portability and Accountability Act and a reduction in the number of employer-sponsored health plans, plan members’ needs are changing. By 20111, roughly $550 billion of premiums will be in the hands of individual decision makers, who either will feel supported by their plans and stick with them or take their business elsewhere.

These shifts in the health insurance marketplace should result in a closer relationship between payer and member, Regan explained. Because of the heightened information needs of cancer patients, payers should look for new ways to communicate with this group more effectively. “Right now it’s unique to have a health care advocate working with you to help you understand your options, but it’s something we need to see more of in the future,” she said.

Payers that intervene early with cancer patients can help them make the decisions that are best for their situation, she suggested, which may improve their outcomes. “If you have surgery first and it wasn’t the best treatment, you can’t go back and undo that,” she said, adding that recent studies have shown that prostate cancer is over-treated with radical surgery 10 percent of the time and with radiation 45 percent of the time. “Payers have people on staff who really can help cancer patients,” she said. “Part of getting it right it is getting involved early enough to make a difference.”

Intervention comes in many forms

Payers also can help cancer patients by providing practical advice that can make the treatment process go more smoothly. For example, individuals undergoing chemotherapy may not know that they can get preapproval for an entire course of therapy instead of getting approval for one treatment at a time. Knowing how to do that saves patients time and stress as they approach their treatment, Regan said.

Further, nurse advocates provided by the payer can potentially assist with treatment decision support, provide important information that will aid the correct choice of physicians and facilities and assist in improving self-management skills during active treatment. “Each physician is dealing with one aspect of your care, but with multiple doctors in the mix, it’s hard for the patient to see the big picture,” Regan continued. With access to a personal health record (PHR), a nurse can look at all of your data, see what treatment you are getting, what your lab values are, and help you understand what progress is being made or what the next steps should be. In addition, the nurse can potentially spot high risk situations and intervene in a way that can enhance patient self-management and prevent treatment related morbidity and costly hospitalizations. ”

She pointed out that PHRs play a key role, especially when the patient is an active participant in capturing their personal past and family histories, and when the treating physicians work together. Today, with personalized medicine, treatments can become very specific to each patient. “Wouldn’t it be wonderful if I knew that my mother, who had breast cancer, took a certain drug and that it didn’t work for her? Perhaps we can tell if it’s not the best therapy for me, either,” Regan explained. “That way, perhaps I could start with a different drug, instead of leaving everything up to trial and error.”

Where cancer patients are treated also has a significant impact on the quality and cost of the care they receive, Regan indicated. “Where you get your care and from whom can make a tremendous difference in the outcome – so much is tied into that – and going to the best doctors to receive the very best treatment for you can actually result in lower overall costs.”

The Journal of the National Cancer Institute found that prostate cancer was less likely to come back in patients whose doctors had performed 250 or more operations (10.7 percent recurrence rate), compared to those patients whose doctors had performed the operation only 10 times (17.9 percent recurrence rate).³

Available tools can help payers improve member contact

Ingenix offers a roster of products and services, including Impact Consumer (PHR), Provider Online Look-up, Ingenix Physician Quality, Ingenix Hospital Quality, Treatment Cost Estimator and Quicken Health, to help payers provide all of their members with the tools they need to better manage their care.

Additionally, Cancer Resource Services (CRS) from OptumHealth, an Ingenix business partner, provides information to help patients make informed decisions about their cancer care and where to receive it. Although CRS focuses on uncommon and complex cancers – where practice variability and expenses tend to be high – it also offers assistance with any other type of cancer.

CRS identifies, credentials and contracts with cancer Centers of Excellence programs nationwide – currently more than 20 Centers – to provide access to patients and provides short-term clinical consulting from experienced cancer nurses to help patients make informed decisions about their care and where to receive it. According to OptumHealth, contracts with CRS offer payers an average of 20 percent to 40 percent savings for inpatient, outpatient and physician services and result in shorter patient stays and lower case costs through a reduction in unnecessary and inappropriate treatment.

In addition, nurse advocates from OptumHealth’s Cancer Support Program go beyond a consultative role by providing focused treatment decision support for high-incidence cancers. These nurses act as an extension of the physician’s office by educating the patient and facilitating early recognition and interventions for treatment-related side effects, and administering depression screens that can lead to appropriate behavioral health interventions that can result in improved quality of life and health outcomes.

More payer help is on the way

Even with these products and services, there still are some important information gaps that need to be filled, Regan pointed out, such as “the ability to measure and compare what’s going on.” Although claims data provide several pieces of the puzzle, it “doesn’t give you a really good picture,” she said.

“You need clinical data that tell you what you need to know about this person, what stage they are in and how they are being treated, such as whether they are being treated in accordance with clinical guidelines. You need to be able to look at how you treat your members and compare that data from hospital to hospital or physician to physician,” she continued.

To solve this problem, Reden & Anders is developing a new and innovative solution for health care payers that can facilitate improvements in care received by patients diagnosed with cancer by driving new insights about provider quality and cost-of-care in the area of several costly cancers at a level of granularity and precision that is not currently available, Regan said.

Currently in the design stage, “Specialty Analytics and Management” (SAM), will involve enhanced data collection and focused analytics around oncology care and consist of a data collection module for collecting and storing clinical data elements from network physicians and an analytics and reporting module for mining and reporting on this data in conjunction with its administrative data complements. “What I am working on right now is how we can get information from payers in a format that is useful,” Regan said. “What we have at the present is workable, but we will have a richer repertoire of data over time.”

According to Regan, “It’s a big endeavor to get involved with members and their care, to say ‘you’re our member and being able to communicate with you is a good thing.’” However, research shows that the more touches a payer has with the patient, the better the experience for both parties will be.

“To help ensure that enhancements are delivered to cancer patients and to the management of individual providers and networks serving these patients,” she said, “payers really need to look at the long view.”

References:

1 “The Retail Revolution in Health Insurance,” The McKinsey Quarterly, March 2007.
2 “Cancer Patients, Lost in a Maze of Uneven Care,” Denise Grady, The New York Times, July 29, 2007.
3 Id.

Be sure to sign up for future issues of Ingenix Innovations, and visit the archive for recent issues.