Precision Oncology and the Payer’s Role in Improving Patient Access

Welcome to Unscripted, the AMCP podcast. A look inside managed care pharmacy

Steve: What happens when employers, health plans, and clinicians and health systems come together to solve some of precision oncology's toughest real-world challenges? To ensure patients are receiving high-quality, timely, and cost-effective care requires active collaboration among the stakeholders who can make that happen.

Open dialogue is essential to drive action and to change the way precision medicine in oncology is delivered and paid for. Welcome to Unscripted, the AMCP podcast. I'm Steve Kheloussi. I'm the Principal Consultant with Kheloussi Consulting and a managed care pharmacist by background. In this episode, we'll be discussing how the Economic Alliance for Michigan is equipping stakeholders to tackle the financial burden of precision oncology head-on, including steps payers can take to ensure appropriate coverage of biomarker tests.

Today, I have the pleasure of speaking with Rachel Unger. Rachel is the Director of Research and Data Analytics at the Economic Alliance for Michigan, where she leads research and collaborative initiatives focused on improving healthcare quality, affordability, and value for employers and their covered populations.

Her current work includes bringing together employers, health plans, providers, and patient advocates to improve access to evidence-based precision oncology care. Welcome, Rachel. We're so happy to have you 

Rachel: Thank you for having me. 

Steve: Of course. And I gave a short introduction, but can you tell the audience a little about the Economic Alliance for Michigan?

Rachel: Sure. So Economic Alliance for Michigan, or EAM, as we're known, is a nonprofit coalition, and we bring together employers and other healthcare purchasers together to improve the value of healthcare in Michigan. And our members represent more than one million lives covered across the entire state. Our work focuses on quality, affordability, transparency, and really practical ways that we can make the healthcare system work better for employees and their families.

What gives us a unique perspective is we sit kind of at the intersection of employers, health plans, providers, policymakers. We're not trying to practice medicine we're not trying to tell clinicians how to treat their patients. Our role is really to ask whether the healthcare being purchased is evidence-based, timely, and delivering value.

And when we see a gap there, we try to bring together all of the right people into the room, better understand the problem, and identify practical solutions. 

Steve: Yeah, I love that. It's, it sounds as though you have this unbiased view going into this conversation about how can we just improve the quality of care that patients are receiving.

And so, you didn't mention anything about oncology. So why are employers focused on precision medicine and oncology specifically? 

Rachel: Yeah. So one of the many pieces of work that we do is in the field of oncology. Cancer is deeply personal for employees and their families. It's also one of the most complex and costly areas of healthcare, and precision medicine really creates this opportunity to match a patient with a treatment that's most likely to work for them in a way that avoids delays, avoids ineffective treatment, and increased spending.

And that completely aligns with what employers' goal is for their coverage and benefit offerings. And we know our employers want the confidence that the benefits that they're purchasing support evidence-based guideline concordant care, and they're not unintentionally creating barriers. But the truth is that employers also typically have a very limited visibility into what's happening throughout the process, from a cancer diagnosis to ordering of tests, coverage approval, start of treatment.

They don't want to practice medicine either. They want to know that their health plan policies support that timely and appropriate care. And our role is to help employers understand the right questions that they should ask, and then bring the relevant stakeholders together to address the parts of the process that may not be working as well as we hope they would.

Steve: Yeah that's really interesting. I've always thought of employers as sort of, entirely reliant on the health plan or, you know, their brokers or whoever they're working with to guide them. But it sounds like they want to ask the questions as well, to make sure that their employees are getting the care that they need and, the coverage that they need for that care too.

So that's really great to hear. So what is the Economic Alliance for Michigan doing in this space? 

Rachel: So we are working with a very broad group of partners including employers, health plans, providers, some quality collaboratives across the state, patient advocate groups, managed care experts, and we're trying to understand where precision oncology could break down in the real world, and then what each stakeholder could do to improve it.

So one of the main things we've been doing in that space is since 2018, we've hosted an oncology symposium annually, and that brings together all of these groups into the same room where we talk about what's working, where barriers still exist, what concrete steps we could take together. And then once we identify where those delays and barriers are occurring, we work with all of our partners to engage with and have conversations with the organizations that are in the best position to address each of those barriers.

And one of the major outcomes of those conversations was the development of an evidence-based care track oncology model. And the idea behind this model is using a shared set of evidence-based guidelines and quality measures to make decisions around care that's designed to reduce unnecessary burden unnecessary variation in care, lessen administrative burden specifically, and support high-value treatment decisions.

And we've begun with initial implementation of the model, focusing really on the coverage of comprehensive biomarker testing for patients with advanced or metastatic non-small cell lung cancer. We've also developed an employer guide, kind of giving back the power to the employers, that helps purchasers have conversations with their health plans and have a clearer understanding about what to ask about coverage for their employees and family members diagnosed with cancer.

Steve: Wow, that's awesome. And I want to go back to one point that you made about this idea of quality measures. So these are not national quality measures. These are quality measures that you and your organization have developed? 

Rachel: Yeah, so we are working with the, they're called the Oncology Stewardship, MOQC, the Michigan Oncology Quality Consortium of the University of Michigan.

And they have been vital in this process for us. They work with many practices across the state of Michigan and they gather some quality measures around different aspects of care that they're focused on. And then we come together and discuss ways that EAM can help improve any of those pieces.

Steve: Wow, that's fantastic. And, you know, complementary to this conversation, AMCP recently just published three supplements in the Journal of Managed Care and Specialty Pharmacy, which I encourage everyone to check out. But, in particular, one is relevant to this conversation, and that is the payer coverage principles for precision medicine, biomarker testing, and oncology.

This is general guidance that we had put out, but it sounds like you've done something similar too, to help plans approach this differently

Rachel: Yeah. So it's, our work in AMCP's payer coverage principles are very complementary to each other. The principles really reinforce a lot of the issues that we've been discussing with health plans, and for us personally, they also provided some helpful guidance on thinking about the next phases of our work.

We have a similar payer discussion guide. We use it in conversations with payers about biomarker testing coverage. So like I said, we're in this initial implementation phase, and what we're doing is meeting with payers both across the state of Michigan and on a national level. We're explaining the goals of our initiative, and then we ask the payers to walk us through their current coverage and prior authorization policies related to biomarker testing and for patients diagnosed with advanced or metastatic non-small cell lung cancer.

And we ask them a few practical questions around their policies, like does a plan distinguish between single gene testing and broader panel testing? Does coverage differ if it's testing is occurring in an inpatient setting versus an outpatient setting? Are there barriers that prevent comprehensive testing from being used in the first place?

We then encourage policies to support at least one appropriate broad panel test without prior authorization or with limited barriers related to prior authorization, also to reduce the reliance on sequential single-gene testing for that initial phase of testing after diagnosis, and also provide greater transparency around preferred laboratories that they're using and provide coverage for.

We have found that frequently coverage looks really good on paper, but that doesn't always equal timely access in practice. Patients could still experience delays, so we're really encouraging employers and health plans to look beyond what a test appears on a coverage policy and ask some questions to kind of get that full picture.

Steve: Yeah, I love that. It's almost as if you're asking health plans to just almost double-check their policies and align them with the real-world implications of what they're asking with the, you know, whatever requirements they're putting in place. Where have you found success in this process? 

Rachel: Yeah. So we have found a very strong alignment around the overall goal.

Every single person that we have spoken to agrees that the appropriate patient should receive the appropriate test, the results should be available as quick as possible, and specifically available when the treatment decision is being made. And that has really helped move the conversation away from assigning blame to a specific stakeholder and towards identifying practical solutions that everyone can help implement.

So because of this, one of our clear successes has really been bringing together those stakeholders in our oncology symposium and just in conversation throughout the year. And they normally only see one part of the process, and we're trying to help them look at that full patient journey, and that makes it easier to identify where a delay or a communication gap is actually occurring.

Steve: Yeah, absolutely. Yeah, those conversations are so crucial to moving this process forward, even just the slightest bit. But the fact that you've been doing it since 2018, I think is a testament to the commitment from all of the stakeholders. That's all fine, but what kind of hurdles have you faced with this process as well?

Rachel: So I guess the other side of working with so many stakeholders and everyone being in alignment is that there's also the risk of what we frequently see, which is fragmentation. When you're working with something like precision oncology that's crossing medical and pharmacy benefits, laboratories, hospitals, pathology, and also rapidly changing clinical guidelines we see a lot of fragmentation.

So each individual organization, they have a process that seems reasonable and correct within their own area, but when you put all those processes together, the overall experience could be confusing or slow or cause some very costly delays, both for the patient and financially. We've also found that another challenge is different parts of the system may update their policies or their workflows at different times.

So if a clinical guideline changes, but the coverage policy changes a few months later, not at that point, or an authorization system is not updated, it may take longer for each piece to catch up. And it's not that a stakeholder has made an obviously incorrect decision, it's that the disconnected process is not working together as smoothly as they need to be for the patient.

Steve: Yeah. That's certainly a struggle. And, you know, going back to your first point there, as part of those supplements that we published from AMCP and the the Journal of Managed Care and Specialty Pharmacy we outlined the stakeholder map basically within this space, and it is unbelievably complicated.

At the center is the patient, but then you have all of these different stakeholders that are playing different roles, and to get everybody on the same page for a given patient is, it's going to take a miracle basically to keep everything flowing. So, organizations like yours that are really working to do this, to help, you know, just better the experience for the patient is so, so important.

And so I want to point out that I think oncology is on every payer's radar, but maybe precision medicine and oncology isn't. So what is something from your perspective that you've learned through this experience that every payer should know or at least consider about this space? 

Rachel: Yeah. We've had some really interesting conversations with payers around this.

So I think that the most important thing is to realize and, and think of it that precision medicine and oncology care are not two separate pieces. They're one piece, part of the same process. Something like biomarker testing, that's part of the treatment decision. It's not two separate things.

So if a test and a therapy are evaluated as two unrelated costs, a plan may make an understandably what they feel decision that appears to save money on, in one area, but it would ultimately lead to greater costs elsewhere, again, both financially and for a patient's health. We know that timing matters so much in oncology, so in order to make the most informed decision regarding treatment, it's really essential that the appropriate coverage is in place to have the necessary testing completed at the right time.

Steve: Yeah and I think that's such an important point, right? Because if the patients are waiting for, let's say, the biomarker test to be ordered to actually go get that test done or to get, the results for that, and all of this is taking time, that takes a mental toll on the patient as well as they know that they have this condition, they want treatment, and sometimes what we've seen in the literature is that it leads to patients getting the wrong treatment first while we're waiting for those biomarker tests, and that leads to downstream costs potentially worse outcomes for the patient unnecessary treatment burden, added side effects, and so on and so forth.

So, to your point, it's so important to get this right the first time for each patient, and it, like I said earlier, takes a the whole health system to work together to do that. So, you know, again, I want to leave our audience with something actionable. So what is, in your opinion, a reasonable first step for payers who are looking to deliver high-quality care, but they still want to keep an eye on their spending within this category?

Rachel: Yeah. So I think the first thing I want to do is acknowledge that coverage is only one piece of this very large process. We're looking at everything. We're not suggesting that one stakeholder is solely responsible for solving it. With that being said, though, I think a reasonable first step would be to focus on one high-impact cancer area and do a review on that plan's biomarker testing pathway. An example would be looking at, let's say, advanced non-small cell lung cancer, and the plan could review whether its coverage policies remain aligned with current evidence-based clinical guidelines and with resources such as AMCP's Payer Coverage Principles, how often they update their policies.

That's a big piece that we see some fragmentation around. They could also look at whether testing and treatment authorizations are coordinated, and they could speak directly with providers and laboratories that they're working with about where delays are occurring in practice. We have found that this type of review can really uncover some meaningful opportunities for improvement and that they don't require completely revamping the payer's design on their oncology policy.

Steve: Yeah, I think you raise a really good point right there at the end. Looking into this more closely doesn't necessarily mean that a payer is going to have to absolutely revamp their entire policy or approach to managing this space. But just, you know, giving it that little bit of extra attention could really make a meaningful difference for the patient and the outcomes in the end.

So Rachel, thank you so, so much. This has been a fantastic conversation, and, that's going to wrap us up. So thank you again to our audience for taking the time to listen today. Have a great day.