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Insights

Jun 11, 2014

New WellPoint Program Will Pay Physicians For Adhering To Oncology Pathways

Published

Jun 11, 2014

On May 28 WellPoint/Anthem BlueCross BlueShield announced the launch of the WellPoint Cancer Care Quality Program – a new pay-for-adherence initiative which incentivizes physicians to follow certain evidence-based WellPoint Cancer Treatment Pathways.

Under the program, which goes into effect on July 1, oncologists will be eligible to receive an “enhanced reimbursement” of $350 per patient, per month, for adherence. The program will initially include pathways for breast, lung and colorectal cancer; however, additional pathways for other cancers will be added in the near future.

Through WellPoint’s program, oncologists will be able to compare planned cancer treatment regimens against evidence-based clinical criteria. Notably, the initiative identifies specific WellPoint Cancer Treatment Pathways when a physician orders a treatment regimen which aligns with the identified pathway. In order for a cancer treatment to be included in a WellPoint Cancer Treatment Pathway, the treatment must be recognized by national guidelines as an “effective and recommended cancer therapy.”  Moreover, WellPoint’s Cancer Treatment Pathways will be reviewed at least quarterly, and will incorporate relevant national guideline updates.

The insurer’s program will be administered by AIM Specialty Health, and apply to all Anthem members, except: 1) Federal Employee Program, 2) Amerigroup, 3) Medicaid, 4) Medicare supplement plans, and 5) Anthem members residing outside of Indiana, Kentucky, Missouri, Ohio, or Wisconsin.

The WellPoint Cancer Care Quality Programs follows the broader trend using various approaches to move physicians to adhere to evidence-based clinical pathways across many types of disease states and care settings.  This step by a major insurer may signal a significant shift toward greater use of efficacy and cost data in clinical decision making. Given the role of clinical practice guidelines (CPG) in pathway development, this development may also lead to a convergence with recent decisions by a number of physician professional societies to begin including cost data in their CPGs. This development also has implications for some stakeholders to consider. For manufacturers of drugs and diagnostics, it further reinforces the need to not only generate high quality clinical and economic data but also ensure these data meet the rigorous standards for favorable inclusion in clinical practice guidelines. Additionally, manufacturers should identify other stakeholders, including researchers or key opinion leaders that may influence the development or refinement of pathways. Given the likely growth in the use of these types of pathways, third-party developers will continue to play a more significant role in design, development, dissemination and maintenance of these pathways.  

WellPoint’s Cancer Care Quality Program takes effect on July 1, with physician orders accepted starting on June 23. While the program will only target breast, lung, and colorectal cancers at launch, the insurer will look to rollout pathways for other cancer types moving into next year.

View more information on the new WellPoint program.

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