The healthcare industry in general, and the treatment of cancer patients in particular, is in the midst of massive change. Balancing the needs of patients with the wide variance in drug costs to develop the right treatment path for each patient is challenging. The growth of real-world data and the rapidly growing analytics capability of artificial intelligence and data science are powerful tools that health plans can leverage to meet that challenge. Today’s oncology landscape is dramatically different than it was even a few years ago so health plans and providers must adapt as well to ensure optimum treatment for patients.

This eBook will explore five key considerations for you to determine the best way to manage oncology drug costs while improving your member treatment options.

Evaluating cancer treatment options is a scary, confusing, and complex process for patients. As a health plan committed to fully supporting your members going through a cancer diagnosis, you must ensure that provider treatment recommendations are backed by science, evidence, and objective data. In addition, implementing a true patient-first approach for oncology treatment requires individualized strategies to address the following challenges:

• Avoiding provider abrasion to maintain a healthy working relationship with clinicians

• Augmenting your internal teams with the most up-to-date oncology drug information
• Ensuring that you are enabling the best, value-based treatment options for your members
  

Putting patients first to help them achieve the best possible outcome is the primary mission of Oncology Analytics. The foundation of our patient-first approach to utilization management is based on optimizing clinical efficacy, toxicity avoidance, and cost-effectiveness in our treatment decisions. Our board-certified oncologists, radiation oncologists, hematologists, and pharmacists have operationalized protocols that cover all cancer diagnoses. These protocols are based on evidence-based guidelines from nationally recognized authorities such as NCCN, ASCO, and others.

100% Oncology Focused

What differentiates Oncology Analytics from other utilization management vendors, is our total focus on oncology. It’s all we do, every day. Our physicians, nurses, and PharmDs are certified in oncology. When providers have questions about a cancer treatment for a member, they will speak directly to a board-

certified oncologist or radiation oncologist. This type of communication substantially limits provider abrasion and ensures that members get the care they need quickly.

Oncology Analytics works in concert with your providers as a dedicated clinical partner and patient advocate. Our treatment decisions are never based on cost alone, and we work to lower patient financial toxicity when possible. Instead of restricting options to certain pathways, we afford the treating oncologist full latitude in their prescribing, only intervening if necessary.

Our staff of board-certified oncologists and oncology pharmacists proactively collaborate with providers on alternative treatment options and provide guidance beyond NCCN 1 and 2A scoring. Our e-Prior Authorization portal takes less than five minutes to submit a case, and our median turnaround time is two hours. All peer-to-peer consultations are conducted by board-certified oncologists, but more than 96 percent of cases do not require a peer-to-peer consultation. In less than 2 percent of cases, a denial is issued, and the provider receives a detailed clinical justification with associated references for the basis of the denial.

The power of putting the patient first means results in you, your members, and your providers achieving the best possible health outcome.

Cancer care is rapidly evolving as new delivery methods and treatment options come online at an aggressive daily pace. The growing number of treatment options, combinations, and additional lines of therapy simultaneously increase the complexity in making an evidence-based determination for ways to treat a patient’s cancer.

As a health plan, you must now employ specific strategies to harness data to achieve optimal patient outcomes while meeting quality and cost goals. However, aggregating oncology data from multiple sources is a difficult task. Gaining immediate, actionable insights from the data is even more challenging.

Need for speed and evidence

A data science-based approach to oncology prior authorization addresses the two biggest challenges associated with making informed and timely patient

treatment decisions: speed and evidence. A data-science approach requires deep analytics and insights into your cancer drug spend to ensure that suggested anti-cancer therapies are based on science and evidence-based protocols, which are specific to the patient’s unique circumstances and needs.

So the question for a health plan to consider is this: How can you equip your team with the right data, paired with the proper insights and actions?

Our data science teams utilize advanced data models and machine learning to better understand outcomes in all areas of cancer treatment to ensure that your members receive the right treatment at the right time and at the right cost. Our comprehensive approach to real-world data and analytics is based on the organization and normalization of clinical data such as EMR progress notes, pathology and lab reports, biomarker data, histology, and stage of cancer. Clinical data is then combined with claims data to provide unique

insights and benchmarks focused on health plans’ oncology spend, trend, and provider network performance.

Specific to creating a long-term, scalable strategy for real-world data and analytics, Oncology Analytics offers a critical technology solution that addresses the primary challenges and gaps you face in advancing a data-driven strategy for oncology utilization management:

Oncology InsightsTM, our next-generation, real-world data analytic software solution, combined with our oncology-focused clinical expertise, equips health plans with superior insight into your provider network, cancer drug trend and spend, cancer treatment decision-making capabilities, and powerful comparative benchmarks.

Since 2018, the FDA has approved 121 new cancer indications, including 49 novel cancer drug entities. The FDA has even launched a Real-Time Oncology Review (RTOR) program, which allows the FDA to review early drug data in advance of a formal application. Under this program, one oncology drug gained FDA approval within two weeks of the application filing.

When it comes to making coverage determinations, checking the box that a cancer therapy is supported by the National Comprehensive Cancer Network (NCCN) alone is no longer enough for a health plan. With so many NCCN supported options, you need to ensure that your providers choose the most cost-effective option, tailored to deliver the best outcome for the patient’s specific cancer.

Importance of a comprehensive review approach

We help you make that choice by taking a more comprehensive approach of

reviewing not only NCCN but also studying FDA approvals and peer-reviewed journals using the Centers for Medicare & Medicaid Services (CMS) coverage rules. We utilize the guidance of our internal oncologists, who have decades of experience caring for patients.

At Oncology Analytics, each oncology review is evaluated using a patient-first approach, which balances the specific clinical need of each patient against comorbidities, toxicities, and cost. This approach facilitates our ability to provide treatment recommendations that reflect the most current evidence-based findings, even when there is a delay between when research is presented and its inclusion in NCCN.

Health plan drug policies play a critical role in the care delivery process, to ensure that treatment decisions are based on clinical evidence and are in the patient’s best interests. While treating oncologists lead the decision-making process for determining the appropriate treatment regimen for their patients, health plans have an essential role to play in supporting this process by providing data and evidence to validate the decision for their members.

In oncology, implementing strong drug policies is critical due to the rapid innovation and pace of new cancer drugs and new indications that enter the market each day. However, the complexity associated with aggregating and analyzing drug data is a significant undertaking. For example, consider the following data points, which must be analyzed and consistently monitored in today’s oncology landscape:

• Comparison to Other Drugs
  Comparisons can be made between existing cancer therapies in a similar space, based on efficacy, toxicity, and affordability. Health plans can use this information to direct steerage into policies, step therapy, biosimilar strategies, or preferred language. Dosing aspects driving cost must also be considered, such as quantity limits, dose rounding, vial size optimization, etc. Furthermore, decisions on whether supportive care agents are required to use the drugs must also be factored.
  
  
• Adverse Reactions
  Well-written drug policies help to quickly quantify and compare side effects among the treatments a patient is eligible to receive. Health plans can help aid decisions by demonstrating which regimens will reproduce those same toxic effects and which regimens will not.
  

Another area that impacts oncology drug policies is clinical trials, which require health plans to have a strategy for both ongoing awareness and data aggregation.

• Robust Knowledge of Clinical Trials
  To determine whether a patient is most likely to receive the benefits derived in a clinical trial, the patient needs to closely match the following criteria: age, ECOG Performance Status, line of therapy, previous agents received, histology, and genetic markers. When comparing results across clinical trials, the rigor of the trial is also considered: meaningful outcomes, such as overall survival, along with sound methodology and clinical phase (III vs. II).
  
  

• Aggregation of Data Across Multiple Clinical Trials
  Every trial provides specific details about how the drug works and in what patient characteristics. The more time spent gathering this type of data, the better for adding details in the drug policy.
  

The growing number of cancer treatment options, combinations, and additional lines of therapy increase the complexity of creating comprehensive drug policies.

Without investing in a team of board-certified oncologists, board-certified oncology pharmacists, data scientists, and researchers, how can you ensure you possess all of the data and analysis needed to develop comprehensive and effective oncology drug policies?

Oncology Analytics can provide you with real-time oncology expertise as an extension of your internal teams, for a fraction of the cost of doing it yourself. Our board-certified oncologists, radiation oncologists, hematologists, and oncology pharmacists focus daily on evaluating and identifying new trends

and researching appropriate therapy combinations. We have deep expertise in medical and pharmacy benefits as it relates to cancer drugs and can help guide you in developing or refining your oncology drug policies.

If your dishwasher needed to be fixed, would you bring it to an auto mechanic? Probably not. Granted, the auto mechanic may possess a general understanding of how machines work but most people would want someone with specific knowledge of dishwashers to fix their issue.

If your dishwasher needed to be fixed, would you bring it to an auto mechanic? Probably not. Granted, the auto mechanic may possess a general understanding of how machines work but most people would want someone with specific knowledge of dishwashers to fix their issue.

Let’s think about this scenario in the context of prior authorizations for cancer treatments. When a health plan receives a treatment request for a member’s complex cancer diagnosis, should it be handled by a general medical professional or an oncologist? If you were the cancer patient waiting for the

decision, who would you want to review and approve your treatment?

The debate over prior authorization is particularly important in oncology, where the wrong treatment approach may mean the difference between life and death. With a myriad of treatment approaches, breakthrough therapies coming to market at a brisk pace, and the high toxicity of some cancer drugs, getting it right is critical. With a larger proportion of costs for health services shifting to employees and consumers through higher co-pays, larger deductibles and narrow physician networks, it is vital that health plans, in partnership with providers, ensure that patients receive the safest, most effective care at the best possible price and outcome.

Data-driven prior authorization

Oncology Analytics is a different kind of partner for oncology prior

authorization. We provide access to current, evidence-based, disease-specific analytics on all cancer types and treatment options, backed by board-certified oncology physicians and pharmacists. We understand the complexity involved in the management of cancer treatment options caused by the rapid pace of research and new drug introductions that are changing the oncology landscape daily.

Our e-Prior authorization solution (ePA,) is data-driven through advanced analytics and helps health plans determine the right anti-cancer therapies. ePA then allows treating oncologists to initiate and manage their prior authorization requests securely through our cloud-based software, which eliminates manual faxing and phone calls, dramatically improving operational efficiency.

Without question, oncology presents unique challenges for prior authorization to be effective. One such example is access to current, evidence-based data and research to make the correct treatment recommendation. As cancer care continues to evolve, the growing number of treatment options, combinations, and additional lines of therapy significantly increases the decision-making complexity for oncologists.

For example, it has been estimated that oncologists would need 29 hours a day1 to keep up with the research and findings that enter the market daily. In just the last 24 months, there have been 32 new cancer therapies approved by the FDA. Partnering with a specialist that focuses exclusively on oncology provides a differentiator for health plans and its members.

In the early days of the 20th century, department store magnate John Wanamaker famously said, “I know that half of my advertising doesn’t

work. The problem is that I don’t know which half.” The same might be said when determining the right treatment for a particular patient. Data science holds great promise if health plans can collect enough data about medical treatments and use that data effectively. The use of real-world data in the prior authorization review and decision-making process should be able to predict more accurately which treatments will be effective for a specific patient and which treatments won’t.

Our comprehensive approach to prior authorization for oncology addresses the in-house resource constraints most health plans face by providing support in two critical areas:

Data-driven prior authorization, which is purpose-built for oncology and provides an in-depth evaluation and analysis of patients through the entire continuum of care, under the guidance of board-certified oncology physicians and pharmacists.

Deep analytics and insights into health plan cancer drug spend, which ensures that anti-cancer therapies are based on science and evidence-based protocols that are specific to the patient’s unique circumstances and needs.

This approach requires that patient cases reviewed by health plans are handled only by board-certified oncologists and oncology pharmacists to ensure that patients receive the “right” care, not just “quick” care.

The Patient First, Cost Effective Solution

Oncology Analytics provides you with real-time oncology expertise as an extension of your internal teams at a greatly reduced cost of staffing up to handle it yourself. Our board-certified oncologists, radiation oncologists, hematologists, and pharmacists focus daily on evaluating and identifying new trends and researching appropriate therapy combinations. We are experts in

oncology medical and pharmacy benefits as it relates to cancer drugs.

Oncology Analytics understands the complexity involved in the management of cancer treatment options caused by the rapid pace of research and new drug introductions that are changing the oncology landscape daily. We are committed to the ongoing review and analysis of oncology treatments, their outcomes, and adverse effects to ensure that all cancer treatment recommendations provide the patient with the opportunity to achieve the best possible outcome.

About Oncology Analytics

Oncology Analytics is a leading data analytics and technology-enabled services company dedicated to helping health plans, providers, and patients with solutions that are purpose-built for oncology. Through an evidence-based, real-world analytics approach to utilization management, Oncology Analytics’ prior authorization platform is used by physicians to support 5 million health plan members in the US and Puerto Rico and covers the full spectrum of therapeutics, across all cancer types and stages, including chemotherapy, radiation therapy, precision medicine, targeted therapy, and supportive care. The extensive pathway library is continuously updated with the latest evidence-based protocols, which provides the most current options for value-based treatment paths for every patient case.

Contact Us

www.oncologyanalytics.com

info@oncologyanalytics.com

Phone: 888.916.2616

Fax: 800.264.6128

7000 Central Parkway, Suite 1750
Atlanta, GA 30328