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      Considering the complexities and cost of radiation oncology

      Delivering value-driven care

       

      Abigail T. Berman, MD, MSCE, Medical Director of Radiation Oncology

      Briefing

      Every cancer treatment journey is as unique as the patient. While cancer care is complex, providing members coverage for value-driven, clinically appropriate treatment in a timely manner, shouldn't be.

      Radiation oncology therapy is used in nearly two-thirds of all cancer treatment regimens globally.1 Advancements in efficacy have promoted improved cancer survival rates from about 30 percent two decades ago to nearly 80 percent today in some cases.2

      Radiation therapy is an important curative treatment for many types of cancers.3 But while its use is critical, it may also be contributing to higher overall health care costs. Cancer care costs are expected to rise in the United States by almost 30 percent to nearly $246 billion by 2030, making cancer a financially as well as an emotionally challenging disease to manage.4

       

      Value-driven care

      Prescribers today are faced with a complicated and multifaceted process that often results in delayed care. Because every patient is unique, each treatment should be too. With no one clear source of guidelines for radiation oncologists, a lack of transparency into current information with often inconsistent, unverified third-party reviews, and an inadequate appeals process, the prior authorization (PA) process for treatment can be complex and lengthy.

       

      97% of procedures require PA5

      73% of radiation oncologists said their patients express concern over PA delays6

      15% of advanced radiation modalities are overutilized7

       

      At CVS Caremark we've created a more streamlined and quality-focused PA experience for providers that helps ensure patients receive clinically appropriate radiation therapy, with minimal delay as part of their overall cancer care. This may help improve health outcomes for patients, as well as increase value for health plans. Our process features:

      Quality – With well-established care pathways and a rigorous clinical review process that aligns with the latest NCCN, ASTRO and literature-based guidelines, we can help to ensure therapy is clinically appropriate.

      Collaboration – Support from board-certified radiation oncologists facilitates reliable peer-to-peer reviews.

      Innovation – Our advanced technology platform makes prescribing and billing easier by guiding providers to select the most appropriate therapy quicker, so patients get started on their treatment, faster.

       

      Radiation oncology represents 14% of overall oncology treatment costs8

      Payors save 5.8% on radiation treatment9

       

      Innovation at the point of prescribing

      With a broad set of integrated capabilities to help payors manage specialty spend across the pharmacy and medical benefit continuum, Novologix, our proprietary cross-benefit technology platform, enables a variety of strategies at the point of prescribing. This helps payors uncover opportunities to address gaps in specialty management while also providing the most appropriate benefit with quicker approvals.

      Novologix features an integrated PA and medical claims management platform with site of care optimization and medical strategies to target high-cost therapies including radiation oncology. By incorporating the most up-to-date clinical guidelines that align with the American Society for Radiation Oncology (ASTRO), the National Comprehensive Cancer Network (NCCN), and evidence-based standards of care, our solution makes it easy for providers to select clinically appropriate therapy quicker, so patients can get started on their treatment faster, which can help improve health outcomes. And our board-certified radiation oncologists are also there to help support cases that require further review.

      Speed, convenience, and reliability are important factors for busy providers. With our PA platform, providers can create a request in as little as six minutes and get a decision in as little as one minute. The system guides them toward appropriate treatment for the request and then helps to guide the process electronically. Complete regimen modality are available for comprehensive cancer care, rather than code-by-code authorizations, as is the case in other marketplace models. And all required documentation can be requested and submitted online, eliminating the need for multiple phone calls and faxes.

      At CVS Health, we're continually building solutions that help improve oncology care experiences and health outcomes, while speeding the process and lowering costs.

       

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      Discover additional insights

      • 1 https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/basics.html

      • 2 Baumann M, Krause M, Overgaard J, Debus J, Bentzen SM, Daartz J, Richter C, Zips D, Bortfeld T. Radiation oncology in the era of precision medicine. Nature Rev Cancer. 2016;16:234–249. [PubMed] [Google Scholar] [Ref list]

      • 3 https://jamanetwork.com/journals/jama-health-forum/fullarticle/2780396

      • 4 https://ascopost.com/news/june-2020/national-cost-of-cancer-care-in-the-united-states-expected-to-rise-to-over-246-billion-by-2030

      • 5 Schwartz et al. JAMA Health Forum. 2021;2(5): e210859. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2780396. Accessed February 24, 2022.

      • 6 https://www.astro.org/News-and-Publications/News-and-Media-Center/News-Releases/2019/Prior-authorization-obstacles-unnecessarily-delay. Accessed February 24, 2022.

      • 7 Savings calculated on commercial fully insured spend on radiation treatment. With an estimated 15 overutilization of advanced radiation modalities, helping ensure that members receive a clinically appropriate radiation modality can help lead to cost savings. CVS Health Analytics, 2022. Data from January 1, 2019, to December 31, 2019. All data sharing complies with applicable law, our information firewall and any applicable contractual limitations. Once we have these claims, we model how the Utilization would have been different if we had shifted 15 utilization from Proton Therapy to IMRT or from IMRT to Conformal Radiation. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan, clinical appropriateness as determined by treating physician, and other factors.

      • 8 DOI: 10.1200/JOP.18.00627 Journal of Oncology Practice 15, no. 8 (August 01, 2019) e704 e716. https://ascopubs.org/doi/figure/10.1200/JOP.18.00627 American Society for Radiation Oncology (ASTRO) 2018 annual member survey. Accessed February 24, 2022.

      • 9 Savings calculated on commercial fully insured spend on radiation treatment. With an estimated 15 overutilization of advanced radiation modalities, helping ensure that members receive a clinically appropriate radiation modality can help lead to cost savings. CVS Health Analytics, 2022. Data from January 1, 2019, to December 31, 2019. All data sharing complies with applicable law, our information firewall and any applicable contractual limitations. Once we have these claims, we model how the Utilization would have been different if we had shifted 15 utilization from Proton Therapy to IMRT or from IMRT to Conformal Radiation. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan, clinical appropriateness as determined by treating physician, and other factors.

       

      The source for data in this document is CVS Health Enterprise Analytics, unless otherwise noted. CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall.

      This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Health.

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