DISEASE MANAGEMENT

Volume 10, Number 1, 2007

© Mary Ann Liebert, Inc.
DOI: 10.1089/dis.2006.622

Oncology Disease Management

DONALD E. FETTEROLF, M.D., M.B.A., FACP,1 and RACHEL TERRY

ABSTRACT

Oncologic conditions are ubiquitous medical illnesses that present a particular challenge for
medical management programs designed to address quality and cost issues in patient popu-
lations. Disease management strategies represent a reasonable and effective approach for em-
ployers and health plans in their arsenal of health management strategies. Multiple reasons
exist for the development of specialized disease management programs that deal with cancer
patients, some unique to this group of individuals. Health plans and/or employers have solid
justification for addressing these issues directly through programs developed specifically to
work with cancer patients. Whether developed within a health plan, or “carved out” to an ex-
ternal vendor, proper evaluation of outcomes is essential. (Disease Management 2007;10:30–36)

INTRODUCTION were those with high volume, high cost and/or

high variability in the expenses experienced by

D ISEASE MANAGEMENT is defined by the Dis-

ease Management Society of America
(DMAA) as a “system of coordinated health-
health plans or employers. These conditions
typically include congestive heart failure, coro-
nary artery disease, diabetes, chronic obstruc-
care interventions and communications for tive pulmonary disease, asthma, and depres-
populations with conditions in which patient sion. More recently, recognition that these
self care efforts are significant.” Disease man- approaches can be extended to other types of
agement: illness in the marketplace has led to disease
management of other diseases and “condi-
• ”Supports the physician or practitioner/pa- tions.” These include obesity, low back pain,
tient relationship and plan of care; and rare diseases, among others. Student ob-
• Emphasizes prevention of exacerbations and servers of the healthcare delivery system have
complications using evidence-based practice always been curious as to why oncologic dis-
guidelines and patient empowerment strate- ease management was not more prominent in
gies; and the selection of programs available for disease
• Evaluates clinical, humanistic, and economic management. As a condition class, oncologic
outcomes on an ongoing basis with the goal illness represents a significant contributor to
of improving overall health.”1 overall healthcare expenses, particularly when
all significant oncologic disorders are com-
As the field of disease management has bined.2 This is especially true for patients in the
evolved, most of the initial diseases targeted last stages of life, where coordination of care is

1Matria Healthcare, Inc., Marietta, Georgia.

2Quality Oncology, a Division of Matria Healthcare, Inc., Vienna, Virginia.

30
ONCOLOGY DM 31

most critical.3 Given their high frequency, sis, particularly in benefit designs that do not
chronic nature, and increasingly high cost of encourage such communication such as pre-
treatment, oncologic diseases are a natural area ferred provider organizations (PPOs) and
for expanded disease management programs. high-deductible indemnity health plans. On-
cologists, in fact, prefer the specialist role over
the more basic primary care physician activi-
ONCOLOGIC DISEASE MANAGEMENT ties, and are not focused on many coexisting
primary care issues.8 The reduced communi-
A specialized disease management program cation and different focus of physicians can
for cancer patients is a reasonable activity to impair the integrated medical and social ap-
pursue. There are a number of issues in oncol- proach needed for patients with cancer.
ogy that suggest that disease management • Public relations issues surrounding the emo-
methods are a clear solution to rising costs and tionally charged issues of cancer care have
increasing quality issues in this field: prevented financially oriented health plans
from developing restrictive medical policies
• Cancer-oriented disease management is a for patients who are often desperate for life-
highly complex field with increasingly com- saving treatments.4
plicated emerging technologies and drugs • Health plans can have a difficult problem in
for dealing with these types of illnesses. In dealing with utilization management and
the case of our organization, it includes 120 quality improvement in cancer patients. It is
different types of cancer and 230 diagnosis- often difficult for health plans to keep up
related groups.4 with complex, emerging technologies and
• There has been a dramatic increase in the treatment options even in the unusual case
number of potential agents to treat cancer of having physicians and nurses who are
diagnoses. The “drug pipeline” is extensive well versed in these treatment modalities.
and filled with extremely expensive treat- • The science surrounding expensive cancer
ments for these conditions—treatments that therapies has advanced more rapidly than
are increasingly being applied in off-label us- the regulatory environment developed to
age. There also has been a dramatic increase monitor them. Widespread off-label use of
in the price of chemotherapy agents, to a chemotherapeutic agents is occurring based
point where these agents may now be ad- on suggestions within the medical literature
ministered in single doses costing as much and the biological disease-targeting ap-
as $25,000–$40,000 each.5 proaches these drugs employ.
• Disease management programs are perfectly • An expanding knowledge of these drugs has
suited to address primary and secondary created the development of numerous ad-
prevention efforts in this field, support ministrative guidelines by the drug manu-
physician practices, and integrate with facturers themselves as well as highly
health plan efforts.6 sophisticated cancer specialty societies. Col-
• Oncology is a complex specialty, with in- lection, maintenance, documentation, and
creasing numbers of relatively uninformed the appropriate application of these guide-
patients. While there is a wealth of informa- lines is a daunting task for any organization
tion available to them, and 67% of Ameri- seeking to develop a clinically robust pro-
cans expect that they can locate reliable med- gram for cancer management. The American
ical information on the Internet,7 it is at times Society of Clinical Oncology (ASCO) quality
overwhelming and is particularly confusing study notes for example, “Initial manage-
to patients who must evaluate how to re- ment of patients with breast and colorectal
spond to their diagnosis. cancer in the United States seemed consis-
• Frequently, weak communication links exist tent with evidence-based practice; however,
between the highly advanced oncology spe- substantial variation in adherence to some
cialists and the primary care physicians tak- quality measures point to significant oppor-
ing care of these patients on a day-to-day ba- tunities for improvement.”9
32 FETTEROLF AND TERRY

• In 2006, CMS has set an important precedent employs. These have been specifically de-
by launching an evaluation of guideline ad- veloped to optimize the processes of man-
herence in oncologic practices for 13 tumor agement for these patients, not simply added
sites. Results of these evaluations suggest on to existing care management or case man-
improved delivery of guidelines and orga- agement programs.15
nizational oversight is warranted and will • There is a steep learning curve to bring up
eventually be considered for additional sites and maintain health plan-focused disease
of disease.10 management programs for cancer therapies
• Regional organizations of oncologists have and patients.
collectively organized into group practices. • Situations unique to employers suggest that
This has obvious potential influences on a separate cancer disease management pro-
many health plan utilization control initia- gram may work better than going through
tives.11 usual channels within their health plans.
• Profit motive for oncologists: Depending on Multiple geographic locations and plans,
how oncologists are reimbursed for chemo- connection with worksite programs, and the
therapy drugs, there may be a profit incen- employer focus on productivity make this an
tive for them to prescribe one drug over an- attractive alternative.16
other in order to maximize their revenue. • Organized vendor programs have software-
• Within the group of oncologic patients, con- enabled access to current guidelines and
cerns regarding end-of-life care and the ap- techniques and a methodology for organiz-
propriate use of treatment modalities in ing and understanding them at an individ-
these patients looms large. Individual pref- ual patient level that is not currently avail-
erence at times may conflict with the eco- able within most health plans.
nomic needs of society or the intervention- • Oncologic drug reimbursement issues re-
oriented approach of oncologic specialists.12 main a particularly vexing area of concern,
Patients need an impartial and unbiased as oncologists’ practice revenues can depend
source of information to work through these significantly on drug administration rev-
issues in a clinical context. enues.17 This has led to concerns by payers
• Disease management programs may prove that additional oversight and review is indi-
especially useful in populations that are un- cated, particularly given the high amount of
derserved or where the administrative in- off-label use of newer drugs. Medicare cost
frastructure can benefit from additional sup- controls were implemented in 2005, but sim-
portive initiatives.13,14 ilar programs are not yet in place in the pri-
• Cost structure and claims complexities make vate sector.18
this an area of important analysis.6,14 • Organizations external to an employer or
health plan are better able to address end-of-
Wide variation in the quality of cancer care, life care without the perceived conflict of in-
with societal response from federal govern- terest and secondary gain that accrues to a
ment to local efforts,9 points in the direction of health plan focused on reducing premium
suggesting that an organized disease manage- cost.3
ment approach is an important solution for • Through their developed programs and em-
dealing with these issues. bedded software, external programs have
Why would an employer or health plan seek dedicated informatics capabilities to create
to carve out cancer management to a disease the analytics and program evaluations nec-
management organization formally structured essary to understand the optimal develop-
to manage these types of patients? Numerous ment of further program elements, and to
reasons exist, some alluded to above: describe the benefits and advantages of can-
cer disease management.
• External organizations have dedicated re- • External entities typically employ clinical ad-
sources to understanding the complexities of visory panels with national experts who can
the oncologic industry and the treatments it recognize local variations that need to be ad-
ONCOLOGY DM 33

dressed and serve as an expert source of in- • The program should focus on patient-cen-
formation to counter individual physician tered care and the individual responses of
claims regarding off-label use of drugs. patients to treatment rather than specific
• External disease management entities con- broad economic targets or a philosophy that
duct rigorous continuous quality improve- is uniformly applied to all patients.
ment activities around patient satisfaction • Programs should identify a multidiscipli-
and can augment National Committee for nary yet comprehensive approach to pallia-
Quality Assurance (NCQA) preparations in tive care and end-of-life care in cancer pa-
the disease management area. tients, and assist patients in moving from a
rigorous treatment phase to a palliative and
To an employer, health plan, or other orga- end-of-life care period of their disease.
nization, what are the characteristics of a good • Programs should have online integrated in-
oncology disease management program? Sig- formatics capabilities and an infrastructure
nificant effort has gone into the development that allows comprehensive reporting and
of oncology management programs over the outcomes measurement.19
past 10–15 years, often beginning with the de- • The program should have a focus on evi-
sirous elements of any disease management dence-based medicine with attention to a
program. These include: directed analysis of off-label use of medica-
tions. Ongoing dialogue should be under-
• Strong clinical support should be available taken to understand whether off-label use is
throughout the delivery of the oncologic dis- appropriate or inappropriate, and effective
ease management program including regu- programs to deal with inappropriate use
lar access to experienced oncologists and should be available and overseen by physi-
program delivery through experienced on- cians. Guideline adherence results in cost as
cology nurses and paraprofessionals. Na- well as quality improvement for these pa-
tional advisory panels composed of leading tients.20
industry experts should meet on a regular • Programs should measure patient satisfac-
basis and review guidelines and answer ad- tion and permit feedback for further pro-
ministrative questions from the manage- gram development.20
ment team. • Disease management programs in general,
• A program should have high-quality knowl- but cancer programs in particular, should al-
edge acquisition and maintenance strategies low multidimensional access to media in a
and easy accessibility to current guidelines. way with which patients feel most comfort-
Programs should have developed ongoing able. Telephonic nurse interaction, online in-
knowledge maintenance with clinical advi- formation, printed materials, and other types
sory panels, regular review and modification of interactions should allow knowledge ac-
of guidelines, and high-level physician input quisition by patients in ways that are most
into the knowledge base necessary to or- comfortable for them in digesting the com-
chestrate these programs. plex issues within cancer management.
• Programs should also pay attention to the • Programs also should offer assistance in nav-
psychological ability of patients to under- igating the complex healthcare delivery sys-
stand the complex information of cancer man- tem for cancer patients as they move through
agement delivery. Experienced cancer nurses hospital and outpatient settings, deal with
significantly reduce anxiety in patients with specialists, and negotiate the complexities of
these conditions and greatly augment com- insurance plan benefit design.
fort with the program as well as improve • Given the emotional nature of cancer, pro-
compliance with complex regimens. grams should have provisions to permit the
• Given the complexity of cancer, case man- discussion of informed consent and offer
agement with a primary care focus, a pri- coaching to individual patients to fully ex-
mary care nurse model is typically em- plore all possible treatment choices available
ployed. to them under all economic circumstances.
34 FETTEROLF AND TERRY

Programs should address the complex social ment guidelines. Guideline compliance rates
and insurance payment issues for the patient and tracking reasons for non-compliance are
and physician under variable benefit designs an important indicator of program effective-
and seek to assist the patient through these ness. Percentage of patients with off-label
often stressful negotiations. chemotherapy use, for example, represents a
• Programs should work with physicians in a good indication across the program as well
collaborative rather than confrontational as geographically or by business class that
way that supports their efforts in a non- the program is monitoring this issue and tak-
threatening way yet challenges them to ing appropriate action. End-of-life care mea-
maintain compliance with appropriate treat- surements such as days in hospice before
ment guidelines. In particular, the use of off- death also point to the effectiveness of a pro-
label drugs for chemotherapy should be ad- gram for this emotionally sensitive issue.
dressed in a way that educates physicians as • Clinical utilization measures typically follow
to benefit design that may not permit inves- those of standard disease management and
tigational use of these agents, but not alien- utilization management industries. Admits
ate or enrage them or the program’s patients. per thousand and days per thousand repre-
• The program should generate regular, tele- sent hospitalization rates that can be com-
phonic follow-up with patients to assess pared against various baselines. Physician
guideline completion, appropriate follow-up profiling statistics are important, particu-
care, and resolution of all outstanding issues larly in documenting physicians who appear
related to the underlying diagnosis. to not follow guideline therapies. The num-
ber of patients completing therapy also rep-
Outcomes assessments in oncologic disease resents both the UM and clinical quality in-
management follow conceptually similar but dicator.
slightly different approaches than traditional • Financial measures are important, but may
disease management programs. A significant be problematic in this emotional area.
amount of effort has occurred at a national level Clearly, financial gains can occur in reduc-
on the appropriate assessment of cancer out- ing unnecessary admissions, readmissions,
comes.21–23 Outcomes metrics are important for and emergency room use, which is the focus
assessing the effectiveness of disease manage- of many case management-oriented pro-
ment oncology programs. Approaches gener- grams. Financial savings also come from
ally follow industry guidelines for the devel- monitoring the inappropriate use of increas-
opment of a disease management program ingly expensive agents. Finally, appropriate
evaluation.24 end-of-life care decisions can dramatically
reduce the use of expensive care.
• Operational indicators include the numbers • End-of-life care measures. Reduction of in-
of members involved in the program and sta- appropriate treatments (“futile care”) used
tistics on those identified versus those actu- at the end of life is also an important source
ally participating in the program. Call cen- of improved quality and cost savings, as pa-
ter statistics—including average speed of tients move from an expensive program to a
answer, abandonment rate, and similar caring hospice end-of-life care program. A
types of metrics—describe the ease of use as great deal of work has been done in this area,
well as functioning of the program. Staffing as the focus of care shifts to patient-centered
structure is also very important in this highly needs at this time.3
specialized field, with staffing ratios of pa- • Other indicators of program effectiveness
tients per nurse as well as educational level specific to cancer management include the
and training of nurses. following:6,9,25
• Clinical quality indicators represent a series
of very important metrics for oncology pro-  The number of patients with cancer by di-
grams, particularly as they apply to compli- agnosis and compared with benchmark
ance with nationally recognized cancer treat- data
ONCOLOGY DM 35

 Member satisfaction survey results 2. Reeder C, Gordon D. Managing oncology costs. Am

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 Whether pain was addressed within one to
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 Hospice enrollment prior to death 7. Horrigan J, Rainie M. Counting on the Internet. Pew
 Hospice enrollment less than 7 days before Internet and American Life Project. Available at:
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 Chemotherapy administration less than 14
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100000f2730ad1RCRD&indexy&pmid8823341.
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Donald E. Fetterolf, M.D., M.B.A., FACP
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December 1, 2006. 1450 Parkway Pl., 12th Fl.
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