Pennsylvania-based Geisinger Health Plan is the most recent payer to announce a partnership with OncoHealth, which has created a platform for managing the cost and complexity of cancer. Healthcare Innovation recently sat down with OncoHealth Chief Medical Officer Andrew Norden, M.D., to talk about changes in the oncology field and the work his company does with insurers.
Healthcare Innovation: Before we get into OncoHealth’s mission, could you talk a bit about your background?
Norden: I'm a neuro-oncologist by training. I spent the first decade of my career seeing patients and working on clinical trials at Dana Farber Cancer Institute in Boston. While I was at Dana Farber, I took on an administrative role overseeing Dana Farber community-based network sites. I got really interested in the quality and the consistency of care across geography and how one maintains that. And in particular, I got excited about the potential for technology to help support those kinds of endeavors. That led ultimately to me leaving the provider world. I first spent time as the deputy chief health officer at IBM Watson Health working on oncology and genomics when that was a brand new entity. Then I was the chief medical officer of an oncology data and analytics company called COTA Healthcare. I've been here at OncoHealth for more than four years now.
HCI: What are some of the ways that the oncology care landscape has been changing over the last several years? And have those changes shaped the services that OncoHealth provides and the needs of the payers it works with?
Norden: Maybe the most fundamental change has been the change from generally applicable chemotherapy that you could give to a whole variety of different candidate cancer types because it's just toxic to growing cells to today's more precision medicine approach that is dependent on molecularly profiling a tumor and then targeting it with a specific drug that goes after that target. That's been emerging for the last 20 years, but it means that each oncology drug that is approved is perhaps more effective than prior therapies, but only for a narrowly defined subset. So payers are looking for help from oncology experts to provide some level of oversight over the way these drugs are being used in their members and ensure that they have the highest possible likelihood of benefit.
A second big factor has been the growth of oral chemotherapy. A lot of those novel drugs that are precision-targeted agents are oral drugs, and they're often given in combination with IV drugs. That presents complexity, and it's also challenging for the payer because traditionally, the intravenous drugs are covered on the medical benefit and the oral drugs are covered on the pharmacy benefit. And generally in payers, there are different organizations looking at those drugs.
Another thing that's been a big challenge for payers is the emergence of exceedingly high-cost and often single-use therapies like CAR T. There are cellular therapies often manufactured for a specific patient. And they may cost $500,000 to $1 million or more. That really challenges payers’ ability to backstop that kind of cost. They want to ensure appropriate use.
HCI: In a press release, your company said that it delivered $230 million in savings, lowering the trend in their health plan partners’ drug spending by 30 percent compared to industry average, and that it averaged a $3,597 rate of savings per engaged member per month. Can you describe how it achieves those type of savings for its partners?
Norden: We work closely with the payers to develop a custom program for them, and we help them implement a variety of policies and procedures that ensure appropriate use of the right drugs in the right patients at the right time. We identify drugs that are frequently used in a non-evidence- based way. We catch those circumstances and engage directly with the physicians to encourage them to make a different choice. And we try to do that in a collaborative, evidence-based way. We work hard to build relationships with the doctors who are treating cancer patients in the community, and we try to help them make evidence-based choices rather than just issuing large numbers of denials. In many circumstances, we're able to steer toward nearly identical drugs or drugs with very similar efficacy and toxicity profiles, but that may have dramatically lower costs.
HCI: In some of those cases, are they unaware of those alternatives or are these sometimes contentious conversations?
Norden: I would say that there are circumstances where oncologists are knowledgeable about the science but may be unfamiliar with the cost implications of different choices. That's a common scenario. There is a smaller set of circumstances where there are recent scientific developments that oncologists just haven't been able to keep up with. Then there are also more scenarios than one would hope where an oncologist lives under perverse financial incentives that reward them or their organization for prescribing something that may be higher cost. I think it's less often the case today than maybe it was 20 years ago that an oncologist stands to directly benefit. But there are economic incentives that oncologists operate under and sometimes they don't align with the realities of what's best for the healthcare ecosystem as a whole.
HCI: Are there cases where these payers and these oncology groups are working in value-based care arrangements, or is that less common in oncology? I know that CMMI has an Enhancing Oncology Model, but is value-based care challenging to implement in oncology?
Norden: I think it's harder to do in oncology than it is to do in a number of other fields for the reasons that we spoke about — both the complexity and rapid pace of change, and the entrenched financial incentives. And the fact that many oncology providers and provider groups are funded materially by the the margin that they can charge on drugs. That's just a longstanding reality of the way that that drugs are paid for in the United States.
I think all of those things work against value-based care, which is why oncology has maybe been slower to come to the table. But with that said, there's a lot of interest in doing more of this. CMS and CMMI have led the way with the Oncology Care Model and now the Enhancing Oncology Model. We talk to commercial insurers about building programs that incentivize high-value prescribing, and encourage the oncology offices to build programs that help ensure patients are kept out of the hospital, out of the ED to the extent that that's avoidable, to encourage the use of appropriate resources at the end of life. We help develop and administer some of these kinds of programs for our payer clients.
HCI: OncoHealth has a new telehealth program in partnership with several payers. One of the goals there is probably keeping people out of the ED and hospital.
Norden: That's right. Our program is called Iris and it is a virtual-first oncology supportive care service. Patients can access our team through an app or through a website or on the telephone. It allows patients who are members of plans that we work with to interact with oncology nurses for symptom management and support. They can get mental health counseling around cancer-specific issues, like fear of recurrence or grief or body image problems. They can get oncology nutritionist support and they can access an enormous array of high-quality vetted information. The goal of this program is to improve their quality of care. It's to ensure that someone is looking after patients in between their oncology visits and providing support for anything that comes up that may be unexpected. They can get their questions answered in a convenient and timely way.
HCI: Could you talk about the new relationship with Geisinger Health Plan? What will you be doing for them? Did they have a pain point that they were seeking help with?
Norden: They wanted to have access to oncology experts who could review the treatment that their members were getting. We have a team that includes a whole bunch of board-certified oncologists. It also includes board-certified oncology pharmacists and oncology nurses. They were looking for expert support around ensuring appropriateness of cancer care, The other part is Iris. There isn't much like Iris out out in the world. So like other innovative health plans, they were excited about the opportunity to expand their members’ access to these services that are hard to come by.
HCI: Because Geisinger is an integrated health system, does that open up opportunities or make this easier because if everyone is part of the same organization, the health plan and the provider side, as far as that conversation with clinicians you were describing earlier?
Norden: Yes, I think so. It's certainly an interesting dynamic, because I just described how internally we have a bunch of clinicians doing this work and yet traditionally, our customer is the health plan, right? We provide services to the patients and doctors. There's no question that when the health plan and the providers are better aligned, we can more seamlessly integrate into workflows and help them in a way that minimizes any burdens.
HCI: Are there any other developments or partnerships you want to mention?
Norden: We really see Iris as a platform that can democratize access to some of the key components of high-quality cancer care that tend to exist in short supply. We hope that we can go beyond the services that I described today to other things like genetic counseling, long-term care and monitoring of survivors, really robust financial counseling, and even home care. That’s the direction that we see this thing evolving over time. We think that there's an enormous need for that kind of thing in the world.
