Biomarkers, Bundled Payments, and Colorectal Cancer Care

Abstract

Changes in the management of cancers such as colorectal cancer (CRC) are urgently needed, as such cancers continue to be one of the most commonly diagnosed cancers; CRC accounts for 21% of all cancers and is responsible for mortalities second only to lung cancer in the United States. A comprehensive science-driven approach towards markedly improved early detection/screening to efficacious targeted therapeutics with clear diagnostic and prognostic markers is essential. In addition, further changes addressing rising costs, stemming from recent health care reform measures, will be brought about in part by changes in how care is reimbursed. For oncology, the advances in genomics and biomarkers have the potential to define subsets of patients who have a prognosis or response to a particular type of therapy that differs from the mean. Better definition of a cancer's behavior will facilitate developing care plans tailored to the patient. One method under study is episode-based payment or bundling, where one payment is made to a provider organization to cover all expenses associated with a discrete illness episode. Payments will be based on the average cost of care, with providers taking on a risk for overutilization and outliers. For providers to thrive in this environment, they will need to know what care a patient will require and the costs of that care. A science-driven "personalized approach" to cancer care has the potential to produce better outcomes with reductions in the use of ineffectual therapies and costs. This promising scenario is still in the future, but progress is being made, and the shape of things to come for cancer care in the age of genomics is becoming clearer.

Payment for Cancer Biomarker Testing

“…At a time when payers, struggling to thrive in the current dynamic health care environment, must clearly understand the cost of patient care, 3 they ''are definitely on board with biomarker tests, particularly when it means that they are paying for drugs that patients will likely respond to-and conversely are not paying for several months of drugs or chemotherapy that will have little positive effect.'' 8 But it has been difficult to ''get a handle'' on biomarker test payment because payment requirements evolve and change over time, payers approach payment in different ways for different technologies, 9 and the majority of payers pay for diagnostic molecular tests separately from the associated therapy.…”

“…Concerns about limited resources, appropriate patient selection, and costeffectiveness of cancer biomarkers is not new 21 ; however, the current economic climate has added rigor and urgency to these concerns. 3,17 Cost-effectiveness and cost-utility studies are commonly used to make payment decisions for new drugs and expensive interventions . .…”

“…Medicare and other payers pay for it because, as cancers display unrestricted growth, frequently dividing cancer cells are killed by the poison-along with some normal cells, hence hair loss and other unpleasant but generally survivable side effects. All that payers traditionally have required in order to authorize payment for chemotherapy has been (1) an understanding the patient actually has cancer (diagnosis); (2) assurance that the poison is not so strong it would kill or otherwise unreasonably harm the patient (safety); (3) and some indication that the poison actually kills dividing cells, such as demonstration of increased survival rates or cure rates (efficacy). Chemotherapy is a ''one-size-fits-all'' treatment and is not usually cost prohibitive, so payers have generally paid for it without much fuss.…”

Directions for Future Patient-Centered and Comparative Effectiveness Research for People With Serious Mental Illness

“…Under a bundled payment mechanism, providers are at risk for overutilization and outliers. 257 CMS began experimenting with bundled payments for coronary bypass in the late 1990s, which resulted in $17 million in savings in the first 27 months of the program. 258 CMS is currently considering implementing bundled payments for hospitals and common inpatient services.…”

Variation in Medicare Payments for Colorectal Cancer Surgery

“…2 Most of this expense is concentrated in the first year after diagnosis, as a result of multimodality treatment costs. 4,5 Traditionally, Medicare makes separate payments to these multidisciplinary providers for each service they perform for the beneficiaries (ie, fee-for-service payments). This approach results in fragmented care and a compartmentalized delivery system, with multiple providers across many health care settings.…”