Cigna’s Integrated Oncology Management Program: Overview, Importance, and Future Directions

Winston Wong: Welcome to the Journal of Clinical Pathways. My name is Winston Wong, editor-in-chief of the Journal, and I will be moderating today's discussion. I am joined today by Dr Robinson Ortiz, oncology medical director for Cigna. Dr Ortiz will be sharing with us Cigna's integrated oncology management program.

Welcome, Dr Ortiz. Dr Ortiz, can you please tell us a bit about yourself, your background, how and when you arrived at Cigna, as well as your role in developing the integrated oncology management program?

Robinson Ortiz: Sure. First off, thanks so much for having me today, Winston. Hopefully, we'll have a very productive conversation. A little bit about myself. I'm a medical oncologist and hematologist by training. I was in private practice in the Chicago suburbs for approximately nine years.

About four years ago, I shifted over to the medical benefit management side. I thought there was definitely an opportunity to have a larger impact at the population level rather than working with individual patients even though I definitely enjoyed working individually with patients to treat malignancies.

Four years ago, I shifted over to the medical benefit management side of things. My main focus the last four years has really been on driving value-based cancer care. As we all know, one of the problems within the oncology space is the drug spend in particular is rising exponentially, and many times, the costs of these medications don't actually reflect the value.

I'm currently the senior medical director at Cigna. My broad goal is to develop a multi-year, multi-faceted clinical and business strategy for Cigna. Thus far with Cigna, it's really been a great experience working for the organization.

Cigna as a whole has gone through some changes recently. Within the Cigna, enterprise constitutes our medical benefits management organization which is eviCore. We also, under the Cigna enterprise, have the pharmacy benefit manager, Express Scripts. Cigna really is a large enterprise with a multitude of different enterprises within the organization.

Dr Wong: Welcome, Dr Ortiz, and thank you for joining us. Let's start with a general overview of Cigna's integrated oncology management program.

Dr Ortiz: Cigna, in general, we have a very robust oncology management program. I think our main focus is always going to be on improving clinical outcomes for patients. We also want to drive affordability, safety with the chemotherapy regimens, as well as help with what I call cognitive overload for providers.

There's just so much information right now for a medical oncologist to consume on a daily basis to stay up to date that it's essentially impossible. Any way we could help in terms of decision support as partners with medical oncologists, most in the community and academic center, I think that's one of our key goals of our program.

Dr Wong: Great. You talked about trying to create a support program for the oncologist. What really motivated you to go and even pursue that? You talked about value-based. That is a current trend in the marketplace today. What do you think even drove that at the very beginning? Was it overutilization, underutilization, inappropriate therapies, the need for improved outcomes?

Dr Ortiz: I think it's all the above. I look at it as a number of problems that we've wanted to solve. One was, despite there being guidelines -- probably, the most well-known are the National Comprehensive Cancer Network Guidelines -- what we did find was that there was still tremendous variation in the chemotherapy regimens that were prescribed, despite the guidelines being in place.

Narrowing down that variation was something we thought would definitely be advantageous. Again, providers just have too much information in front of them to really be experts in all tumor types. We wanted to help them through decision support to make the best decisions for their patients.

Also, a key component is there still tends to predominate misaligned incentives with oncologists as far as the fee-for-service model that we're all aware of, whereas oncologists are incentivized not based on the quality of care that's provided but on the overall volume and cost of care that is provided.

Probably, the most important factor involved in development of our program is really the exponential rise in oncology drug costs that are taking place today from five years ago to today.

Looking at the average cost of a drug coming onto the market, it's just been an astronomical increase. Some of the new drugs are $200 to $300, $400,000 per year, which in the long run, I could see not being sustainable, and access to care could be compromised.

Really, there was a multitude of factors, a multitude of problems, within the oncology space that I felt like we were at the correct point to try to dig into this. If not solve all the problems, at least make a significant dent in them.

Dr Wong: Listening to what you just said, I think the implication then is that your pathway program goes deeper than just following the NCCN Guidelines. It is definitely a narrowed set of treatment regimens that you are evaluating and promoting?

Dr Ortiz: Exactly. The oncology clinical pathway program that we have, all the regimens that we have as our pathway regimens are a subset of NCCN recommended regimen. There'll be no pathway regimens that are outside NCCN recommendations.

What I think sets us apart is the methodology that we use in order to determine what subset of those NCCN recommended regimens are going to be our preferred pathway regimens.

When we took a look at everything that are going on within the oncology industry the last few years, we were impressed with the ASCO Value Framework. They now have a version two that's available that helps to identify high-value treatment regimens.

The European Medical Oncology Society also has a value framework as well. You're probably aware of NCCN has Evidence Blocks, which also helps to hone in on high-value regimens. There's also ICER that you're likely familiar with, which is also a tool used to determine the quality and value of cancer care.

When we were looking at all these value frameworks, what we came up with was a proprietary methodology to incorporate all these frameworks into our own proprietary tool that really narrows in on the highest-value treatment regimens for the patients. I think that sets us apart from some other pathway program.

It's our rigorous methodology and our use of multiple value-based frameworks. They all have their pluses and minuses, but I feel like when we consolidate their inputs together, we come up with the highest-value treatment regimens for patients.

Dr Wong: I'm assuming then that you're subcommittees per se, per cancer type come from CAOLs throughout your network then?

Dr Ortiz: We have a very rigorous process to validate the regimens that we're selecting as our pathway regimens in addition to using the value-based frameworks. We have internal oncologists that are over 10 board-certified medical oncologists as of right now. We also have a large number of oncology pharmacists. We also have an enterprise-wide P&T committee that reviews all of our pathway selections.

Also outside Cigna, we engage with an external community oncology advisory panel where we're really taking some of the experts in each tumor type and getting their input.

We also have an external academic advisory panel where we're taking experts from some of the leading academic medical centers, and we're providing them with which pathways we have chosen the rationale behind it and getting their clinical input before we make final determination.

It's a rigorous validation process in addition to these value-based frameworks that we're using to identify the pathway regimens that we've selected. I feel like across the industry, we set ourselves apart by having this rigorous methodology and rigorous validation process for our pathway program.

Dr Wong: That's impressive. That is, I think, clearly a differentiator of your program versus everybody else. I would assume that you are going back to the same traditional triad of efficacy, tolerability, and cost at the end. You're bringing outcomes into that as well.

Dr Ortiz: Definitely. What we're always going to first look at is, what's the clinical efficacy and safety of a regimen? If that's clearly superior versus other regimens, then that will be on pathway.

Affordability and cost wouldn't even be factored into the equation. The only time cost and affordability is factored into our equation is when there's comparable regimens with equal efficacy and toxicity. That's a great point.

Dr Wong: Great. How do your network oncologists get engaged into the program then? Is it a pre-certification process that they have to go through anyway, not the accountability but the tabulation of whether you're consistent with a preferred pathway or not is inherent to that pre-certification process?

Dr Ortiz: The clinical pathway program, it's embedded within to the prior authorization process, but it's still a voluntary program. When a provider were to go in to make a selection through the eviCore prior authorization portal, regimens are going to be populated that are consistent with the NCCN guidelines.

The pathway regimens will be highlighted as a subset within those regimens. Providers have the option of choosing amongst all the NCCN recommended regimens, but again, we're highlighting the pathway regimens within that prior authorization tool. In that respect, we're trying to use it as decision support for providers.

As you know, sometimes NCCN can list 10, 15, 20 different options. Narrowing it down to two or three maybe high-value regimens can be helpful for the oncologists. Thus far, the program was rolled out January 1st of 2021. The feedback that we've gotten from community oncologists has been very favorable as far as the program. We're very excited about that.

One thing to point out is, if a provider in some instances were to select a regimen that was not considered a pathway regimen, a board-certified medical oncologist from eviCore would reach out to that provider and have a peer discussion with the provider to figure out the rationale behind why they may not be choosing a pathway regimen and to provide supporting evidence for why we have selected that pathway regimen in the first place based on the rigorous criteria I mentioned.

Many times, providers aren't aware of all the latest literature, the latest publication, the latest NCCN guideline updates. NCCN has updated, for example, the non-small cell lung cancer guidelines five, six, seven times over the last year or so.

Again, as a decision support tool with our medical directors reaching out to providers for these peer discussions, the response we've gotten has been very favorable from medical oncologists.

Dr Wong: Great. I believe you said your program started in January of '21?

Dr Ortiz: Correct, so definitely a new program.

Dr Wong: Do you have a sense of the -- I don't want to use the word compliant -- consistency rate with the guidelines prior to the start was?

Dr Ortiz: The consistency rate for NCCN adherence based on the rigorous process, eviCore, has been doing has always been, I would say, quite good, but we're still in the early stages of determining what are pathway adherence is.

Some early data coming back is showing that the adherence to our pathway regimens have increased since implementing the program, but some specifics, we're still working through since it's been very early in the program development.

Dr Wong: You mentioned the updates. As you mentioned, non-small cell lung has updated, it seems like, almost every other week in the past three months or so. To your rigorous process, what's the timing in terms of updates then to your pathways?

Dr Ortiz: At the moment, we don't have a specific timeframe where we're going to say, "OK, NCCN-related updates, or if there's a new publication in the 'New England Journal of Medicine,' this will be reflected on a pathway within one to two weeks."

As of right now, we're working through that, and we have certain individuals on the clinical side that they're dedicated to looking up updates through the NCCN. They get flash updates on a daily basis. The major publications are always coming out with newer oncology-based studies and updates on studies.

Ultimately, our goal is to incorporate updates as quickly as possible based on FDA approvals, NCCN updates, and the newest literature. I don't have a precise timeframe, but suffice to say that we're going to be doing updates quickly based on how the evidence is changing quickly in the oncology space. Definitely, that's going to be an important component of our program.

Dr Wong: In your tracking of your consistency to your pathways, is it on an oncologist basis, or is it a practice basis?

Dr Ortiz: That's something we're also still looking at, but I think ultimately in a future state, we will be able to look at what practice compliance is, as well as at the provider level. Again, that's still something we're working out, and we haven't established yet.

Dr Wong: The last question in terms of reporting is, do you report back to practices?

Dr Ortiz: That's also a great question. Again, as of right now, since its new program, we don't have that in place as of right now, but that will definitely be a future state because we're going to want to have that input with maybe practices that may have a lower level of compliance to find out.

Are there clinical exceptions for reasons they're not following pathways because they have a unique patient population, or is there some sort of educational component we could potentially do with the providers to help them make decisions for their patients that will lead to the best outcomes?

Dr Wong: The last question I have really is, with it being a new program and looking at the future state, do you envision the program being coming part of some type of a value-based arrangement with the practices?

Dr Ortiz: Another great question. As of right now, Cigna has a value-based care program called the Oncology Focus program. Our own clinical pathways have not yet been integrated into that value-based care model, but I definitely see in a future state that our pathway program being incorporated to the value-based care models that we do develop within Cigna.

As you know, value-based care models, lessons are to be learned from many of the models going on across the industry. As we're learning lessons, as we're learning from our own models, we're going to be...As a future state, I definitely see ourselves as incorporating our pathway programs as a pillar of our value-based care model.

Dr Wong: A question you don't have to answer, but I'll ask it. If you can, please answer. With that value-based model that you have, are the metrics, both outcomes-based metrics as well as financial? If financial, how do you account for, let's say, an increase in use of targeted therapies?

Dr Ortiz: That's a great question as well because it can be very unpredictable just to what degree these targeted therapies, the cost can be for them. It can be difficult to incorporate these into value-based care models.

Again, as a future state, we're going to want to look at detailed projections of some of these targeted therapies and what the costs might be so that we could actually try to make the most accurate benchmarks for what future cancer therapy costs might be, not just in the targeted therapy space but even outside the targeted therapy space.

I think that benchmarking is going to be critical. We're looking at different methods to have the most accurate projections as possible for what the cancer spend is going to be because, as you know, within cancer care, the drug spend is the largest portion of the total cost of care within oncology.

Dr Wong: I'm assuming later on, as you start looking at the performance or the impact of your program, you'll be looking at emergency room visits and inpatient admissions as well?

Dr Ortiz: Definitely, definitely. There's also quality components to our value-based care model, and those are exactly ones that are incorporated into it. Quality is going to be a huge component as well.

Dr Wong: Is there anything else you'd like to have our listeners learn about your program?

Dr Ortiz: I just want to emphasize that as of right now, oncology care is really at a crossroad. It's mainly because of the overall exponential rise in cost of cancer care. I really think this is the right time to strongly intervene as much as we care to thrive value-based cancer care.

The other point that I want to emphasize I've mentioned numerous times, it's just that oncologists are overwhelmed with the amount of information that they have to absorb on a daily basis. I read one study saying that for an oncologist to keep up with all the data, they'd have to be reading 29 hours a day, which we all know is not possible.

Being a partner with our oncologists is critical component of our program. In a nutshell, that's the main goals of our program. Again, anyone can reach out to me directly if they want more information about our new program, but thus far, it's been successful. I'm excited to see how things are going to unfold in the future.

Dr Wong: Great. Thank you, Dr Ortiz, for a very interesting discussion. It's always interesting to hear and learn about perspectives of different payers with respect to managing oncology. I can tell you for one, having been in the payer space for at least the last 25 years, your program is definitely different from a lot of the ones that are out there. It's much more robust. You're going in a great direction.

As always, thanks to the Journal of Clinical Pathways for the opportunity to have this discussion. Finally, thanks to the audience for taking the time to listen in on this discussion. For the latest updates on issues related to the development, implementation, and evaluation of clinical pathways, please check out our website at www.journalofclinicalpathways.com. Have a good day.

Dr Ortiz: Thank you, Winston.