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4/17/2013
THE 2013 GENENTECH
ONCOLOGY TREND REPORT
Perspectives From Managed Care, Specialty
Pharmacy Providers, Oncologists,
Practice Managers, and Employers
©2013 Genentech, South San Francisco, CA
December 2013
Mission Statement
The mission of The 2013 Genentech Oncology Trend Report:
Perspectives From Managed Care, Specialty Pharmacy
Providers, Oncologists, Practice Managers, and Employers is to
provide timely and useful information on the latest cancer care
trends and developments. Updated annually, the publication is
designed to serve as a unique resource for those seeking an
understanding of the issues surrounding cancer management
and practice. The content of this report was prepared by Emron
with the guidance of an editorial board and is based on primary
research of key stakeholders, as well as published literature.
Statements and opinions contained in this report do not
necessarily reflect the opinions of Genentech.
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4/17/2013
Current Edition
The 2013 Genentech Oncology Trend Report
●
Includes a number of longitudinal analyses of trends since the
inception of the publication
●
Uses information from secondary resources in each chapter
to support survey findings
●
Added new questions to each of the surveys to capture
stakeholders evolving strategies related to the following
– Cancer drug shortages
– Oncology practice consolidations
– Risk-sharing and integrated payer/provider initiatives
– End-of-life and palliative care
– Site-of-service management
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Sample Size and Demographics
Survey group
N
Region
Other Details
Managed care
organizations (MCOs)
101
National: 19%
Regional/state: 81%
Average # members
Medical benefit: 2.8 million
Pharmacy benefit: 2.6 million
Specialty pharmacy
providers (SPPs)
21
National: 91%
Regional: 9%
Ownership
9 PBMs; 4 Independents;
2 Health delivery systems;
6 Other
Oncologists
159
NE: 24% W: 23%
MW: 19% S: 35%
Community practice: 52%
Academic/medical center: 31%
Hospital-based: 17%
Oncology practice
managers (OPMs)
100
NE: 27% W: 16%
MW: 20% S: 37%
Community practice: 58%
Hospital-based: 28%
Academic/medical center: 12%
Government institution/clinic: 2%
Employers
101
National: 35%
Regional: 65%a
# Employees
100-500: 30%
>500: 70% PT: 18%
aState-level
Status
FT: 82%
organizations are considered part of the applicable region.
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Key Themes Across Stakeholder Groups
Cancer Drug Management Efforts
Payer & SPP cancer drug management
Oncology Practice Consolidation,
Workload & Staffing
Integrated payer/provider initiatives
Practice consolidation
Guidelines & pathways
Trend toward hospital-based oncology care
Pay-for-performance programs
Oncologist workload
Cancer Drug Spending & Revenue
Advanced practice clinicians
Payer cancer drug spending
End-of-Life & Palliative Care
Oncology practice cancer drug purchasing
& revenue
Cancer Survivorship Care
Mandatory use of SPPs
Coverage & Access to Cancer Drugs
Impact of cost sharing on patients & practices
Drug shortages
SPPs & cancer drug access
Pharmacogenomics
Disease Management
Health Information Technology
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Cancer Drug Management Efforts
 Payer cancer drug management
 SPP cancer drug management
 Integrated payer/provider initiatives
 Guidelines & pathways
 Pay-for-performance programs
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Payer Cancer Drug Management
MCOs rated closed specialty pharmacy networks as their
most effective means of controlling cancer drug costs
Percentage
of MCOs
Effectiveness
rating
Prior authorization protocols
89.1%
3.30
Drug quantity/days’ supply limitations
81.2%
3.16
Member cost sharing via dollar copays and percent
coinsurance
67.3%
2.75
Adjusted drug reimbursement to lower expenditures
56.4%
3.25
Step therapy
55.4%
3.30
Closed specialty pharmacy network
52.5%
3.38
Specialty drug benefit design recommendations
40.6%
2.90
Preferred drug therapy
39.6%
2.83
Limited first fill (ie, short fill)
33.7%
2.94
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SPP Cancer Drug Management
The three most effective strategies for cancer drug cost
control reported by surveyed SPPs
1
42.9%
Promoting the use of preferred drugs
2
Creating value through compliance/
38.1% persistency programs
3
Negotiating with manufacturers
28.6% for better pricing
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Integrated Payer/Provider Initiatives
●
Nearly half of MCOs reported pursuing new integrated
payer/provider initiatives with oncologists to improve cancer
care, such as
– Forming an oncology accountable care organization (ACO)
– New risk-sharing arrangements/payment models
●
The percentage of oncology practice revenue tied to global
payment arrangements has been increasing steadily over the
past 3 study periods, as has the percentage of practices
negotiating such an arrangement
7.4%
38.0%
50.0%
2010
2011
2012
of practices in
of practices in
of practices in
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Integrated Payer/Provider Initiatives (cont.)
●
In 2012, only 1.9% of surveyed oncologists and 3.0% of surveyed
OPMs reported that their practices are currently moving forward with
partners to organize an accountable care organizations (ACOs)
Oncologists (N=159)
OPMs (N=100)
Not on our radar screen
Trying to understand the
regulations
Currently investigating
Monitoring the experiences
of other practices*
Do not know
Moving forward with
partners to organize
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Guidelines & Pathways—MCOs
●
72.3% of MCOs reported current or planned guideline/pathway
use (up from 65.6% last study period)
– 29.0% tie incentives to voluntary use
– 11.6% tie oncologist reimbursement to mandatory use
●
About half of MCOs rated
their guideline/pathway
use as slightly or moderately
effective in enabling quality,
cost-effective care
Not at all
effective
Slightly
effective
Moderately
effective
Very effective
Extremely effective
Still measuring
program impact
Unsure/do not know
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Guidelines & Pathways—Oncologists & SPPs
●
69.8% of surveyed oncologists reported using cancer
treatment guidelines/pathways in 2012
(up from 59.5% in 2009)
– 24.3% of oncologists have contracts with payers
whereby their reimbursement is tied to specific
guideline/pathway use
●
Two-thirds of SPPs reported supporting oncologist
guideline/pathway use in 2012
(up from one-third in 2011)
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Coverage & Access to Oncology Drugs
 Impact of cost sharing on patients & practices
 Drug shortages
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Impact of Cost Sharing on Patients & Practices
●
Cancer drug cost-sharing requirements continue to increase and
to affect a larger share of members under the pharmacy benefit
(vs the medical benefit)
– 55.4% of surveyed MCOs do not currently align cost sharing across
medical and pharmacy benefits
“Most common” member cost sharing for oncology agents in 2012
Ranges appear in parentheses
Commercial
Managed Medicare
Mean fixeddollar copay
Mean
coinsurance
Mean fixeddollar copay
Mean
coinsurance
Medical
benefit
$76.90
($5–$250)
18.4%
(0%–30%)
$36.50
($0–$75)
20.6%
(0%–33%)
Pharmacy
benefit
$56.38
($5–$250)
19.6%
(0%–50%)
$45.94
($3–$100)
27.5%
(10%–35%)
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Impact of Cost Sharing on Patients
& Practices (cont.)
●
In 2012, OPMs reported that
they collected the entire share
of cancer drug out-of-pocket
payments from only 29.6% of
their patients
●
46.3% of surveyed practices
sought financial assistance
from charitable organizations
for their patients in 2012
●
27.7% of patients were
eligible for help from
manufacturer assistance
programs, with an average
58.8% success rate
Share of patient’s drug cost share collected
(N=95)
(N=100)
(N=100)
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Drug Shortages
Nearly
of oncologists agreed or strongly agreed that
recent drug shortages have disrupted their
treatment plans and threatened public safety
– 76.0% of practices impacted by drug
shortages have had to substitute drugs in
place of the standard of care
Only
of SPPs have formal programs to address
drug shortages
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Cancer Drug Spending & Revenue
 Payer cancer drug spending
 Oncology practice drug purchasing & revenue
 Mandatory use of SPPs
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Payer Cancer Drug Spending
Cancer drug spending growth rates have increased
steadily for four straight study periods
Drug-only cancer spending
(anticipated)
●
The cost of cancer drugs and their administration now account
for one-third of MCOs’ total cancer spending, on average
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Payer Cancer Drug Spending (cont.)
Employers rated cancer drug costs as the most significant
driver of their overall cancer care costs
●
44.6% of employers have purchased stop-loss coverage to
limit their financial exposure to catastrophic medical claims
– 10.9 % plan to purchase such coverage in 2013
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Oncology Practice Drug Purchasing & Revenue
●
Cancer drug acquisition costs accounted for an average of
41.1% of oncology practices’ total expenses in 2011
– More than half of community-based OPMs expect
this percentage to rise by the end of 2012
●
On average, practices buy and bill more
than half (55.8%) of their cancer drugs,
another 27.5% are purchased/supplied
by hospitals, and 16.7% come from SPPs
– One-fifth of practices purchase oral cancer
drugs and dispense them directly to patients;
another 13.2% plan to do so in 2013
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Mandatory Use of SPPs
●
SPPs estimated that
about two-thirds of
their managed care
contracts require
oncologists to obtain
oral oncology agents
from them, instead of
through a wholesale
buy-and-bill channel
in 2012—up from
about half of
contracts in 2011
Average percentage of managed care contracts
requiring oncologists to obtain drugs
through SPPs
(n=15)
(n=12)
(n=17)
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Oncology Practice Consolidation,
Workload & Staffing
 Practice consolidation
 Trend toward hospital-based oncology care
 Oncologist workload
 Advanced practice clinicians
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Practice Consolidation & Other Reorganization
Strategies
●
According to OPMs,
8.0% of oncology
practices have joined/
combined with another
practice
– Another 29.0% are
Practice reorganization strategies to improve
financial performance
Affiliate with a group
purchasing organization
Affiliate with a practice
management organization
considering doing so
●
17.0% of practices have
integrated with or
entered into a joint
venture with a hospital
– Another 6.0% have
Integrate or enter a joint
venture with a hospital
Join or combine with
another practice
Sell practice to a hospital
been sold to a hospital
Currently implemented
Under consideration in the next 2 to 3 years
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Oncologist Workload
●
The average percentage of time oncologists spend per week on
“patient care” has declined slightly over the past 5 study periods—
from 88.0% in 2008 to 83.1% in 2012
– The average number of patients seen
during a typical day has also declined
●
The majority of surveyed
oncologists continue to report
increased personal workloads
– May reflect the intensity of
Changes in oncologist
personal workload in 2012
Decreased
Remained the same
Increased
patient services and time
spent outside of direct patient
care due to administrative
and payer-related issues
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Oncologist Workload (cont.)
●
More patients with cancer is the leading factor influencing
oncologists’ workload changes
Percentage of
oncologists
Factors fueling workload changes
More patients with cancer
42.7%
More patients requiring a high intensity of services
41.8%
More clinical trial participation
37.3%
More time spent on reimbursement and payer-related issues
35.5%
More patients under survivorship care
30.0%
Practice improvements
29.1%
Increased market competition
29.1%
Reimbursement issues require more time spent with patient
27.3%
Practice has added services
25.5%
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Advanced Practice Clinicians (APCs)
●
6 in 10 practices reported
employing APCs (eg, nurse
practitioners and physician
assistants)
●
The primary role of APCs in
most practices is for patient
follow-up visits
●
Oncology practices were
most likely to report plans to
add/expand the number of
APCs on staff in the next 2
to 3 years to improve their
financial performance
(followed by administrative/
claims staff and oncologists)
Percentage of practices in 2012 at which this
is a “primary role” for APCs (n=100)
Patient follow-up
office visits (outpatient)
78.0%
64.0%
Patient education
Triage patient
telephone calls
Attend to low-maintenance
patients
58.0%
48.0%
Cancer patient initial
visit and workup
45.0%
Clinical trial research
coordination
44.0%
Sick and emergency
patient visits
39.0%
Act as a “scribe”
during office visits
38.0%
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End-of-Life & Palliative Care
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End-of-Life & Palliative Care—MCOs
●
76.2% (n=77) of surveyed MCOs have undertaken initiatives to improve
palliative care and end-of-life planning
Initiatives
Percentage
of MCOs
Case manager/nurse telephonic support
81.8%
Print and Web site educational materials
59.7%
Patient education from palliative specialist
27.3%
Physician training on how to discuss with patients
24.7%
Working with network oncologists to develop guidelines for advanced care planning
22.1%
Investigating new reimbursement method for physician services
13.0%
Increasing physician payment for palliative care and end-of-life planning
9.1%
Incentives for earlier palliative discussions in advanced cancer patients
6.5%
Consulting with employers on enhancing inpatient and outpatient hospice coverage
5.2%
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End-of-Life & Palliative Care—Employers
●
Surveyed employers are most concerned about benefit
coverage of cancer screenings, case management, and
care navigation
– However, coverage of end-of-life and palliative care are a
greater priority than they were in 2011
Percentage of employers providing
benefit coverage related to end-of-life
and palliative care
Inpatient hospice care
63.4%
Outpatient hospice care
62.4%
53.5%
End-of-life counseling
Access to palliative care
41.6%
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End-of-Life & Palliative Care—Oncologists
●
86.2% of oncologists reported always or frequently discussing
palliative care options and advanced care/end-of-life
planning with patients—oncologists view this primarily as
their responsibility
– Only 6.3% of oncologists reported that “other” staff members
always discuss palliative care and end-of-life planning
with patients
Palliative care options and
advanced care/end-of-life planning
Oncologists 
Other staff 
39.0%
6.3%
47.2%
37.1%
Always discuss
13.9%
56.6%
Frequently discuss
Never/rarely discuss
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End-of-Life & Palliative Care—SPPs
●
Half of surveyed SPPs offered palliative care and end-of-life
planning services in 2012, such as
– Pain medication management
– Counseling from board-certified palliative care pharmacists
and/or trained SPP staff nurses
– Referrals to external palliative care specialists
31
Cancer Survivorship Care
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Cancer Survivorship Care
●
One-third of oncologists reported that having more patients
under survivorship care has fueled changes in their workload
OPMs report who is responsible for survivorship care
3.0%
Oncology practice coordinates
some care with the patient’s
primary care physician
19.0%
46.0%
Oncology practice
Patient’s primary care physician
Other
32.0%
●
One-fourth of practices employ staff as care navigators to
coordinate services between the oncology practice and
referring and/or primary care physicians
33
Pharmacogenomics
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Pharmacogenomics—MCOs & SPPs
●
One-fourth of MCOs restricted coverage of cancer drugs to
favorable genomic/companion diagnostic test results in 2012
●
MCOs also reported on their current approach to the
management of genomic laboratories/vendors
35.6%
Nothing at this time
Early stages of
strategy development
Evaluating vendors
30.7%
15.8%
Limiting coverage to preferred
vendors or platforms
●
22.8%
One-third of SPPs offered pharmacogenomic services to
MCOs in 2012 as part of their oncology services (up from
one-fourth in 2011)
35
Pharmacogenomics—Oncologists
●
●
●
The past 3 study periods have seen
an increase in the percentage of
oncologists who “frequently encounter”
prior authorization restrictions dependent
upon pathology, tumor typing, or
genomic marker testing
53.5% of oncologists reported referring
more patients to genetic counseling and
genomic testing in 2012 vs 2011
Percentage of oncologists
frequently encountering
prior authorization for testing
37.1%
21.9%
18.0%
2010
2011
2012
47.8% of oncologists reported that genetic tests/biomarkers
have moderately or significantly improved the cost-effectiveness
of their therapy decisions…
– 39.0% reported little to no impact
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Disease Management
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Disease Management
●
Only 25.7% of MCOs offered a disease management (DM)
program for cancer in 2012
– DM programs are primarily developed internally by MCOs
– DM programs are most commonly created for patients with breast,
colorectal, prostate, and lung cancer
●
47 employers offered DM programs as part of their health
benefit plans in 2012
– 35.6% of those offer a cancer DM program
– Such programs most often include
• Case management
• Education about cancer screening/prevention
• Web-based resources
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Health Information Technology
39
Health Information Technology
●
The use of health information technology by oncology practices has
increased significantly over the last 4 study periods
Use of health system information technology
(Percentage of respondents)
(N=158)
(N=150)
(N=183)
(N=159)
EHR = electronic health record; eRx = electronic prescribing.
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Health Information Technology (cont.)
●
The use of electronic health records
(EHRs) has had mixed results in
their impact on the number of
patients oncologists are able to see
●
68 oncologists participate in the
Centers for Medicare and Medicaid
Services “meaningful use”
EHR Incentive Program
– 20 met criteria for Stage 1
meaningful use in 2011
– 34 expect to do so in 2012
– 12 are “unsure” of their status
Change in the number of
patients oncologists are
able to see since working
with an EHR system
49.1%
25.9%
25.0%
Increased
No change
Decreased
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Health Information Technology (cont.)
●
62 OPMs reported on
practice changes
planned for the next
2 to 3 years to improve
financial performance
– About half anticipate
adding/expanding their
eRx and EHR systems
●
Two-thirds of SPPs
reported offering/
planning to offer mobile
apps to support patient
order status, refill
reminders, and patient
adherence
Percentage of
practices (n=62)
eRx system
53.2%
EHR system
50.0%
Clinical trial participation
38.7%
Financial counseling services to help
patients secure out-of-pocket funds
35.5%
Referrals to hospitals for treatment
30.6%
Oral drug dispensing
29.0%
Diagnostic imaging/scans
29.0%
Use of specialty pharmacies for drug
procurement
25.8%
Nutrition services
25.8%
Social worker support and services
25.8%
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4/17/2013
THE 2013 GENENTECH
ONCOLOGY TREND REPORT
Perspectives From Managed Care, Specialty
Pharmacy Providers, Oncologists,
Practice Managers, and Employers
©2013 Genentech, South San Francisco, CA
December 2013
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