2018 cancer concerns of United States health plans. (21st September 2018) - Brook, R. A.
Abstract: Background: Cancer care is shifting from chemotherapy to more effective targeted immunotherapies with fewer side-effects. New therapies, some existing therapies with expanded indications (including maintenance) and many therapies with price increases require re-evaluation. Objectives: To identify the cancers most concerning to managed care plans. Methods: A survey invitation was sent to senior officers of US health plans and pharmacy benefit managers (PBMs). Respondents completed an online interactive survey. Topics included: officer + plan information, cancer ranking (lowest = 1-to-13 = highest), copays, benefit design, cancer management, concerns today and in 5 years from budgetary and medical points of view (POV) and compare current results with prior surveys. Results: The survey was completed by 77 respondents; 57% were MDs and 43% were the senior officer, 19% were payor specific, 9.9% regional, 1.3% therapeutic area specific. 40.5% of respondents worked for health plans, 11.4% for PBMs, 8.9% for integrated delivery networks (IDNs), 3.8% for preferred provider organizations (PPOs)/independent physician associations (IPAs), 1.3% for government. Plans cover multiple types of members: commercial (68.8% = fee for service [FFS], 76.5% = health maintenance organization [HMO]/PPO), Medicaid (Traditional = 36.4%, HMO/PPO = 67.9%), Medicare (71.2%, PDP-only = 50%), Employer/Self-funded = 77.1% and IDN (47.7%, 340B = 43.5%). Oncology was tied for the 3rd highest ranked Specialty Pharmacy condition covered 81.8% (64.3% in 2016) and 47.5% of respondents reported they participated in Oncology accountable care/disease management organizations (34.1% last year). Genomic tests for Oncology were covered by 87.7% of plans. The cancers ranked most concerning were: Lung = 11.1, Breast = 11.0, Colon + Rectal = 9.6, Non-Hodgkins Lymphoma (NHL) = 7.7, Prostate = 7.4, Leukemia = 7.0, Myeloma = 6.9, Melanoma = 6.8, Pancreatic = 6.5, Kidney = 5.1, Bladder = 4.7, Endometrial = 4.5 and Thyroid = 11.38. NHL increased in rank to 4 (from 9 last year), myeloma decreased to 7 (from 5). When asked about cancer management 68.9% (increased from 48.7%) of the sometimes leave oncology specialists alone, 58.7% (decreased from 65%) always follow NCCN guidelines, 61.4% (increased from 56.4%) sometimes follow other guidelines or pathways, and 52.3% (increased from 38.5%) sometimes follow internal protocols. Cancer/oncology was consistently reported the top concern from medical care (47.2% today, 50% in 5 years) and budgetary (50% today, 60.9% in 5 years) POVs. Conclusions: The shift from chemotherapies toward targeted immunotherapies and the cost implications requires plans to focus on, evaluate and adapt to newer agents and pathways. New maintenance indications are causing plans to evaluate long-term coverage.