How to Manage Overutilized Services for Breast Cancer

October 2, 2017

In 2017, nearly 253,000 new cases of invasive breast cancer will be diagnosed in U.S. women, according to breastcancer.org.1 This continues a troubling trend: One in eight women will develop invasive breast cancer during their lifetimes.1

 

Cancer treatment costs patients time, health, and quality of life. And there are tangible costs to patients and to payers as well. In 2010, breast cancer cost $16.5 billion in direct expenses in the United States.2

The right treatment at the right time for the right diagnoses can help minimize cost and improve quality of care. Enhanced decision making by attending oncologists through sharing evidence in collaborative, peer-to-peer engagement makes these wins possible.

And this is where the tumor board model of cancer care comes in.

The Proven Advantage of Tumor Boards

Tumor board review is a treatment planning approach in which many doctors who are experts in different medical specialties review and discuss a patient’s medical condition and treatment options.

A 2006 University of Michigan study found tumor boards changed diagnoses in 45 percent of cases, with a corresponding change in surgical management in 11 percent of cases.3 A team from the University of Pennsylvania reported that its multidisciplinary breast tumor boards recommended a change in treatment for 43 percent of patients referred to the center.4 And a 2009 study from New Zealand showed gynecologic tumor boards resulted in changes in diagnosis and surgical management in 9 percent of cases after histopathologic and radiologic reviews.5

Traditional tumor boards, though, aren’t without their issues. Decision making by the tumor board members can be driven by facility profits, rather than always being patient-centric. The way to overcome this problem? An independent third-party to manage the tumor board.

The Advantages of a Third-party Virtual Tumor Board

HealthHelp’s Collaborative Oncology Model (COM) is a virtual tumor board (VTB) designed to manage and improve cancer care and minimize the amount spent on a per member per month basis.

The COM focuses health care coordination activities on patient-centeredness and on evidence-based medical practices. HealthHelp’s medical director of oncology and board-certified specialists in oncology and related specialties, including medical oncology, radiation oncology, surgical oncology, and pathology comprise HealthHelp’s COM VTB.

Through technology and expert guidance on how to best use data points, HealthHelp identifies health plan members likely to incur high-cost services and develops treatment pathways in consensus with the treating oncologists to provide optimal, efficient care.

The treatment pathways involve best practices that include breast-conserving therapies, hypofractionation, evidence- and cost-based chemotherapies, and appropriate types and frequencies for diagnostic and staging imaging.

Early intervention eliminates unnecessary imaging, biopsies, radiation therapies, surgeries, and medical oncology treatments.

Satisfaction in a Real-world Example

In a study published by the National Center of Biotechnology Information, researchers found that virtual tumor board participants were happy with the VTB services provided at UNC Lineberger Comprehensive Cancer Center, which connects community-based clinicians to UNC tumor boards.6 Researchers used an embedded case study design with UNC VTB as the overarching case, comprised of multiple tumor boards representing different cancer types, each with individual clinician participants.

“Cases presented at VTB were appropriate, sufficient information was available for discussion, and technology problems were not common. UNC clinicians viewed the VTB as a service to patients and colleagues and an opportunity for clinical trial recruitment,” researchers wrote.

In the regular denial utilization management (UM) model, cost-containment happens only when an authorization request comes through to the payer or its benefit manager. “UM companies have always faced challenges in getting providers to agree to alter their practices because the ability to educate the provider in traditional UM is very limited,” said Poonam Chadha, the director of program management at HealthHelp.

With HealthHelp’s VTB model, physicians collaborate to develop the best options for the most efficient and effective treatments courses for plan members. Better care, better outcomes, and lower costs are wins across the health care continuum.

Contact HealthHelp at 800-405-4817 or visit http://www.healthhelp.com/oncology/ for more information.

Sources:

1 “U.S. Breast Cancer Statistics,” breastcancer.org, March 10, 2017. http://www.breastcancer.org/symptoms/understand_bc/statistics

2 “Breast Cancer by the Numbers: Facts and Statistics,” Healthline, November 17, 2014. https://www.healthline.com/health/breast-cancer/facts-statistics-infographic

3 “Solid Tumor Board Changes Childhood Cancer Treatment Courses,” University of Michigan Health Lab blog, September 28, 2016. http://labblog.uofmhealth.org/rounds/solid-tumor-board-changes-childhood-cancer-treatment-courses

4 “Multidisciplinary Management of Cancer Patients: Chasing a Shadow or Real Value? An Overview of the Literature,” U.S. National Library of Medicine, August 19, 2012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410834/

5 “The Multidisciplinary Tumor Conference in Gynecologic Oncology—Does It Alter Management?” P Cohen et al.  Int J Gynecol Cancer 19 (9), 1470-1472. 12 2009 https://www.ncbi.nlm.nih.gov/labs/articles/19955920/

6 “Assessing the Feasibility of a Virtual Tumor Board Program: A Case Study,” U.S. National Library of Medicine, May 1, 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116610/

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