Real Time Market Intelligence (RTMi) Case Study for Prostate Cancer

August 19, 2020

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.

Methodology Chart
(Click to Expand)

Sampling of Participants

Title

  1. Medical Director
  2. Formulary and Contract Manager
  3. Medical Director
  4. Senior Medical Director
  5. Medical Director, Western Region
  6. Medical Director
  7. Medical Director
  8. Medical Director, NW Region
  9. Medical Director
  10. Chief Medical Officer

Plan Affiliation

  1. Rees-Sealy Medical Group/Sharp Healthcare
  2. SelectHealth
  3. HealthNet of California
  4. Priority Health
  5. WellPoint/Anthem
  6. Humana
  7. Aetna
  8. United Health Group
  9. Independence Blue Cross
  10. Harvard Pilgram Health Care

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
      • Care is provider-driven
    • 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)
Last modified: August 20, 2020
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