WellPoint Inc. is offering a reimbursement incentive to oncologists who follow treatment regimens that follow specific "pathways" identified by the insurer.
The program, announced May 28, will provide oncologists with $350 in additional reimbursement for the initial treatment in one of three cancer categories – breast cancer, colorectal cancer, and non–small-cell lung cancer – that follow the pathway established by WellPoint. Providers registered into the program will get an additional $350/month for following treatments identified in the pathway.
It is being rolled out first in Indiana, Kentucky, Missouri, Ohio, Wisconsin, and Georgia and will expand to other states throughout the balance of the year and into 2015 and covers fully insured and self-insured members, Medicare Advantage members and national account members who live in states in which the program has launched.
Dr. Jennifer Malin, medical director for oncology at WellPoint, notes that the program is not meant to be one that drives oncologists to specific treatments and that providers can deviate from the pathways if that is what is considered the best treatment option for their patients without any penalty to normal reimbursement terms of the member’s health plan.
<a href="http://polldaddy.com/poll/8101237/">Should more insurers adopt an incentive program for following particular oncology treatment plans?</a>However, WellPoint is expecting that the pathways will be followed. According to a document outlining the pathways – 24 for breast cancer, 16 for colorectal cancer, and 22 for lung cancer – pathways "are not available for every patient medical condition but are intended to be applicable for 80%-90% of patients. ... Given the complexity of cancer and all of the unique individual circumstances, it would not be possible to have a pathway for every specific situation. The treating oncologist will determine if, in his/her medical opinion, a pathway treatment is the best option or whether, given his or her unique circumstance, another treatment regimen will be a better treatment for him or her."
The document said the pathways are developed "using a rigorous process of evidence-based medicine," and are based on clinical benefit, safety/side effects, especially those that lead to hospitalizations and impact quality of life, strength of national guideline recommendations, and cost of the treatments. They differ from clinical practice guidelines "in that the objective of a pathway is to identify a subset of regimens supported by clinical evidence and practice guidelines with the goal of further reducing unwarranted variation in care and cost."
Dr. Malin, who also continues her clinical practice by volunteering at the Veterans Affairs Greater Los Angeles Healthcare System, says the program will not interfere with the trend toward personalized medicine.
"Pathways are tailored to the evolving science of genomically targeted therapies," she said. "In addition, multiple regimens are included to provide options for oncologists to personalize therapy to their individual patient."
For example, there are six pathway options for first and subsequent lines of therapy for treating metastatic breast cancer in HER2-negative patients. In fact, most pathways offer at least two options, with the exception of colorectal cancer patients with metastatic disease and KRAS mutations on third or subsequent lines of therapy (only treatment with regorafenib is eligible for the reimbursement bonus) and first-line treatment of metastatic non–small-cell lung cancer that is ALK positive (crizotinib).
WellPoint says it will review identified pathways at least quarterly, if not more often, to ensure the evidence continues to support inclusion, or if new guidelines or therapies emerge that warrant change or inclusion, and the document asks providers to submit feedback on an ongoing basis.