CHALLENGE
- Understand the perceived unmet need for diagnostic testing in early-stage prostate cancer
- Gain insight on the levels of evidence required by payers to obtain biomarker coverage in prostate cancer
- Discuss alternative approaches in development of genomic biomarkers and associated evidence
- Test the value hypothesis of a new diagnostic test in early-stage prostate cancer
APPROACH
- Leverage The Lynx Group’s unique access to advisors pertinent to this initiative
- Contract 10 key advisors (preapproved blinded titles)
- Utilize RTMi (a real-time platform) to gain timely and accurate feedback on a weekly basis
- Provide strategic guidance to facilitate contracting, question design, ongoing participant management, weekly summaries, recommendations, executive summary, and strategic recommendations
OUTCOMES
KEY FINDINGS were incorporated into brand strategic plan and dissem-inated to account managers at POA meeting and in training materials. Brand is now covered by Medicare and most commercial payers.
(Click to Expand)
Sampling of Participants
Title |
- Medical Director
- Formulary and Contract Manager
- Medical Director
- Senior Medical Director
- Medical Director, Western Region
- Medical Director
- Medical Director
- Medical Director, NW Region
- Medical Director
- Chief Medical Officer
|
Plan Affiliation |
- Rees-Sealy Medical Group/Sharp Healthcare
- SelectHealth
- HealthNet of California
- Priority Health
- WellPoint/Anthem
- Humana
- Aetna
- United Health Group
- Independence Blue Cross
- Harvard Pilgram Health Care
|
|
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Sample of Insights: Prostate Cancer
- Overall, payers are not pleased with the value they are receiving for their spend in this category
- The following reasons were given for suboptimal value in the category:
- Lack of ability to accurately stratify patients
- Variation in care – some physicians (especially urologists) treat too aggressively
- Needle biopsies – repeat biopsies conducted too frequently; too many patients needlessly receiving biopsies
- Too much IMRT
- Lack of shared decision-making between providers and patients
- Cost of newer CRPC drugs (Provenge, Zytiga, Xtandi)
- Plans are reluctant to manage initiation of ADT after PSA rise, citing lack of unequivocal evidence and lack of clinical pathways in prostate cancer
- Several plans (Harvard Pilgrim, United, Anthem) are moving toward narrow physician networks as a way to reduce variation in care
- Performance-based contracts are becoming increasingly common
- In national plans, the use of narrow networks varies by region
- None of the participating plans surveyed had different criteria for community vs academic-based urologists
- Likewise, none had different criteria for urologists and medical oncologists
- Overall, advisors perceived that a diagnostic test that helped to stratify risk in prostate cancer could offer a great deal of value
- Most advisors indicated that a risk stratification test would be more useful than a screening/identification test
- A good risk stratification test would be especially useful in younger working populations
- For payers, a risk stratification test would provide value by reducing variation in care
- Better target candidates for active surveillance
- Reduce unnecessary procedures and treatments
- Help alleviate physician concerns about litigation (in the event of undertreatment)
