Consolidation within the oncology provider community, including hospital acquisitions of oncology practices and oncology practices joining together, is changing the dynamics in the relationship between providers, health plans, and pharmaceutical companies. The gain of size through consolidation gives practices bargaining leverage and leads to more centralized decision making on the prescribing and administration of cancer therapies. Faced with a slate of expensive oral and infused therapies, including an exciting new immune checkpoint inhibitor, managed care organizations are challenged to contain their pharmacy costs for treating members with advanced metastatic renal cell carcinoma while also preserving their members’ access to life-altering therapies. This content examines how consolidation in the oncology sector has affected the reimbursement and prescribing environment for renal cell carcinoma therapies.

Questions Answered in This Report:

· Consolidation of oncology practices through hospital acquisitions and practice mergers has implications for prescribing of renal cell carcinoma drugs. How widespread is the consolidation trend among surveyed MCOs and oncologists? Have costs to health plans risen as a result? How are MCOs responding to the trend?

· Consolidation can erode the autonomy of oncologists who become employees of health systems. What reasons do some oncologists give for the loss of prescribing autonomy in the hospital setting? How does becoming part of a hospital system affect oncologists’ prescribing of renal cell carcinoma drugs? What impact do MCO-imposed utilization management restrictions have on oncologists’ prescribing?

· Consolidation has often been linked to increased use of the 340B discount drug purchasing program and physician dispensing of oral oncolytics. Are oncologists more likely to prescribe oral renal cell carcinoma drugs when they have access to their own in-house pharmacies? Are MCOs reimbursing physicians for in-office dispensing? Are physicians more likely to prescribe premium-priced therapies if they have access to 340B pricing?

Scope:

· Markets covered: United States.

· Primary research: Surveys of 100 medical oncologists and 40 managed care company officials, including 22 pharmacy directors and 18 medical directors in August 2016.

· Indication coverage: Advanced, metastatic renal cell carcinoma.

Table of contents

  • Renal Cell Carcinoma - Access & Reimbursement - Detailed, Expanded Analysis (US): “The Changing Face Of Physician Autonomy: How Consolidation Among Oncology Practices Is Affecting Market Access For Renal Cell Carcinoma Drugs”
    • Actionable Recommendations to Optimize Market Access
      • Successes and Stumbles
        • Successes Among Renal Cell Carcinoma Therapies in the United States
        • Stumbles Among Renal Cell Carcinoma Therapies in the United States
        • United States: Reimbursement Successes and Stumbles
        • Key Stakeholders in the Road to Market Access
          • United States: Stakeholder Dynamics in the Road to Reimbursement
        • Key Market Access Roadblocks
          • Reimbursement Dynamics
            • United States: Commercial Managed Care Organizations
              • Reimbursement Lessons Learned and Key Takeaways
              • Drivers of Reimbursement by MCOs for Renal Cell Carcinoma Therapies
              • Pricing and Reimbursement Drivers in Renal Cell Carcinoma
              • Key Findings
              • Restrictions Commonly Used in Commercial Plans for Renal Cell Carcinoma Therapies
              • Hurdles Within Prior Authorization for Renal Cell Carcinoma Drugs
              • Impact of Prior Authorization
            • Impact of Practice Consolidation
              • Key Findings
              • MCOs' Observations and Predictions for Oncology Practice Consolidation or Acquisition by Hospitals
              • MCOs' Reaction to Oncology Practice Consolidation or Hospital Acquisition
              • MCOs' Observed Effects of Hospital Acquisition or Consolidation of Oncology Practices
          • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
            • Patient Share in Key Payer Channel
              • Key Findings
              • Commercial Patient Share for Renal Cell Carcinoma Therapies by Type of Practice
              • Top Prescribing Drivers for Renal Cell Carcinoma
              • Factors Affecting Oncologists' Choice of a Renal Cell Carcinoma Therapy
            • Prescriber Preference
              • Prescriber Preferences for Renal Cell Carcinoma
              • Most-Prescribed Renal Cell Carcinoma Therapies in the First Line
              • Most-Preferred Renal Cell Carcinoma Therapies in the First Line
              • Most-Prescribed Renal Cell Carcinoma Therapies in the Second Line
              • Most-Preferred Renal Cell Carcinoma Therapies in the Second Line
            • Impact of Payer Policy on Prescribing
              • Key Findings
              • Physician-Reported Most-Impactful Restrictions
              • Key Levers and Constraints on Select Renal Cell Carcinoma Therapies
            • Impact of Practice Consolidation on Prescribing
              • Key Findings
              • Effect of Hospital Ownership on Oncologists' Prescribing Autonomy
              • Effect of Hospital Ownership on Oncologists' Prescribing of Specific Renal Cell Carcinoma Drugs
              • Effect of Oncologist Practice Consolidation on Oncologists' Prescribing Autonomy
              • Factors Inhibiting Prescribing Autonomy Among Oncologists in Consolidated Practices
              • Effect of Oncology Practice Mergers on Prescribing of Specific Renal Cell Carcinoma Drugs
          • Market Access Landscape for Emerging Therapies
            • Likely Impact of Emerging Therapy
              • Potential Commercial Patient Share for Renal Cell Carcinoma Therapies in the First Line After Avelumab and Yervoy Become Available
            • Potential Placement of Emerging Therapy at Various Prices
              • Potential Reimbursement of Emerging Therapies for Renal Cell Carcinoma
              • Likely MCO Reimbursement Structure for Avelumab/Inlyta Combination Therapy
              • Likely Tier Placement for Avelumab in MCOs' Largest Commercial Plan
            • Prescriber and MCO Opinion on Remaining Unmet Need
              • Oncologists' Mean R&D Priorities for Emerging Therapies in Renal Cell Carcinoma
              • Pharmacoeconomic Data Sought by MCOs for an Emerging Renal Cell Carcinoma Therapy
          • Methodology
            • Primary Market Research Methodology - Physicians
              • Specialty of Surveyed Oncologists
              • Post-Residency Practice Experience
              • Number of Renal Cell Carcinoma Patients Seen by Oncologists
              • Renal Cell Carcinoma Therapies Prescribed by Oncologists
              • Oncology Practice by Region
              • Oncology Practice by State
              • Breakdown of Community-Based vs. Hospital-Owned Oncology Practices
              • Insurance Coverage for Cancer Patients
            • Primary Market Research Methodology - MCOs
              • Distribution of MCO Respondents by Job Title
              • Distribution of MCOs by Region
              • Distribution of MCOs by State
              • Operations of MCOs: National, Regional, or Single State
              • Types of Health Plans Offered by MCOs
              • Distribution of MCOs by Number of Covered Lives
              • Average Number of Lives Managed by Surveyed MCOs
              • Commercial Tier Structure
          • Appendix
            • Physician Survey
              • Ownership Structure of Oncology Practices
              • Number of Oncologists in Locally Owned Practices
              • Type of Institution Reported by Hospital-Based Medical Oncologists
              • Compensation of Hospital-Based Oncology Practices
              • Oncology Practice Ownership Change, Past Five Years
              • Oncology Practice Consolidation Among Nonhospital Practices
              • Oncology Practices' Anticipated Ownership Change in One Year
              • Oncology Practices Anticipated Consolidation Method
              • Expected Compensation After Anticipated Hospital Acquisition
              • Ranked Reasons for Oncology Practices' Recent/Anticipated Consolidation
              • Oncology Practice Consolidation Effect on Use of MCO Specialty Pharmacy
              • Anticipated Loss of Prescribing Autonomy Among Oncologists in Hospital-Acquired Practices
              • Oncologists' Anticipated Change in Prescribing of Renal Cell Carcinoma Therapies Due to Hospital Ownership
              • Anticipated Loss of Prescribing Autonomy Due to Consolidated Oncology Practice
              • Oncologists' Anticipated Renal Cell Carcinoma Prescribing Change Due to Practice Consolidation
              • 340B Pricing Effect on Use of High-Cost Oral Therapies
              • In-House Dispensing of Oncology Drugs by Practice Ownership Type
              • Advantages of In-House Dispensing of Oncolytics
              • Renal Cell Carcinoma Drugs Dispensed by Oncologist-Affiliated Specialty Pharmacy
              • Effect of On-Site Specialty Pharmacy on Prescribing of Oral Drugs vs. Injected Drugs
              • Utilization of Clinical Pathways in Renal Cell Carcinoma Drug Prescribing
              • Source of Clinical Pathways Used by Oncologists
              • Effect of Oncology Practice Consolidation on Narrow Network Inclusion
              • Effect of Narrow Network Inclusion on Cost-Conscious Prescribing
              • Formulary Used in the Prescribing of Oral Renal Cell Carcinoma Therapies by Hospital-Based Oncologists
              • Comparison of Restrictiveness of Hospital and MCO Formularies for Renal Cell Carcinoma Therapies
              • Channels Used to Obtain Renal Cell Carcinoma Therapies, by Practice Type
              • Therapies' Inclusion in Bundled Payment Arrangements, by Practice Type
              • Effect of Oncology Practice Size on Margin for ASP-Priced IV Drugs
              • Oncology Practices' Use of Group Purchasing Organizations and Buying Consortia for Oral and IV Agents
              • Effect of Oncology Practice Consolidation on Meeting PA Requirements
              • Oncologists' Attention to ASCO's Health Benefit Score Program Developments
              • Oncologists' Anticipated Utilization of ASCO's Value Framework for Renal Cell Carcinoma
              • Oncologists' Preference for ASCO's Measurements Within the Value Framework
              • Oncologists' Preference on ASCO's Inclusion of Patient Reported Outcomes in the Value Framework
              • Anticipated Effect of ASCO's Value Framework in Prescribing of Renal Cell Carcinoma Drugs
              • Anticipated Effect of Cost Data and ASCO NHB Scores on Prescribing
            • MCO Survey
              • MCO Formulary Type of Largest Commercial Plan
              • Average Total Membership of Surveyed MCOs' Pharmacy and Therapeutics Committees
              • Formulary Status of Newly Approved Therapies for Renal Cell Carcinoma Prior to P&T Action
              • Typical Time Required Post-Launch for P&T Drug Review, UM Criteria
              • Top Influencers for Renal Cell Carcinoma Drugs Within MCOs' Pharmacy & Therapeutics Committees
              • Information Required by P&T Committees for Review of Renal Cell Carcinoma Drugs
              • MCO Reimbursement of Renal Cell Carcinoma Drugs Within Pharmacy Benefit, Medical Benefit
              • Determination of Reimbursement Under Medical or Pharmacy Benefit
              • Coverage Status for Renal Cell Carcinoma Drugs in MCOs' Largest Medicare Advantage Plan
              • Coinsurance Percentage Payment Required for Specific Renal Cell Carcinoma Drugs, MCOs' Largest Commercial Plan
              • Copayment Amounts for Specific Renal Cell Carcinoma Drugs in MCOs' Largest Commercial Plan
              • Medical Benefit Copayment Charges for Drugs Separate from Office Visit Charge
              • Coinsurance Percentage Charged Under the Medical Benefit for Renal Cell Carcinoma Drugs
              • Copayment Amount Charged Under Medical Benefit for Renal Cell Carcinoma Drugs
              • Pharmacy Controls for Specific Renal Cell Carcinoma Drugs on MCOs' Largest Commercial Plans
              • Presence of Dispensing Pharmacies Within Local Oncology Practices
              • Effect of Practice Consolidation on Oncology Practice Costs of Renal Cell Carcinoma Drugs
              • Percentage of MCOs' Oncology Network Physicians Employed by Hospitals
              • Anticipated Percentage of Network Oncologists Employed by Hospitals in One Year
              • Future Proportion of Oncology Network in Hospital-Owned Practices
              • Incidence of Higher Reimbursement to Oncology Practices Newly Purchased by Hospitals
              • Reimbursement Increase for Oncology Practices Newly Purchased by Hospitals
              • MCOs' Concern Over Costs of Hospital Ownership of Oncology Practices
              • Effect of Oncology Practice Mergers on MCOs' Oncology Reimbursement
              • Percentage Increase in MCOs' Reimbursement to Merged Oncology Practices
              • MCOs' Concern Over Cost Increases Due to Oncology Practice Mergers
              • Inclusion of Renal Cell Carcinoma Drugs Within Bundled Payments for Renal Cell Carcinoma Treatment
              • MCOs' Response to Increased Use of 340-B Pricing Due to Consolidation
              • MCOs' Anticipated Outcomes from Consolidation in 12 Months
              • MCOs' Perceived Effect of 340B Pricing on Prescribing of High-Cost Drugs and on Hospital Acquisitions
              • MCOs' Observed Effects of Hospital Ownership on Cost of Oncolytics, Renal Cell Carcinoma Drugs
              • MCOs' Reactions to Increased Costs Due to Increased Use of Hospital-Based Infusion Sites
              • Impact of Product Preferencing on the Medical Benefit
              • MCOs' Concern About Increased Physician Dispensing of Oral Oncolytics
              • MCOs' Reimbursement of Oral Oncolytics Dispensed by In-House Oncology Pharmacies
              • MCOs' Adjudication of Oral Oncolytics Dispensed by Oncology Practices/Hospitals
              • Anticipated MCO Adjudication of Oral Oncolytics Dispensed Through Oncology Practices/Hospitals
              • Main Distribution Channel Used for Specific Renal Cell Carcinoma Drugs
              • MCOs' Perception of Hospital-Owned Practices' Resistance to White-Bagging
              • Oncology Practice Consolidation's Effect on Volume Purchasing of IV Oncolytics
              • MCOs' Attention to ASCO's Development of a Value Framework for Oncology Drugs
              • MCOs' Potential Use of the ASCO Value Framework in Future Reimbursement Decisions
              • MCOs' Preferred Comparator for a Clinical Trial of an Emerging Renal Cell Carcinoma Therapy
              • MCOs' Placement of Yervoy on Medical, Pharmacy Benefit
              • MCOs' Considerations for Preferred Placement of Yervoy When It Launches
              • MCOs' Considerations for Preferred Placement of Avelumab When It Launches

        Author(s): Paula Wade

        Paula Wade tracks and analyses the national trends in the U.S. health insurance industry for Decision Resources Group. She produces the company’s Managed Care Organization Analyzer products and has authored several of DRG’s Physician Payer Dynamics reports.

        A former newspaper journalist with a background in survey research, Ms. Wade has also worked in healthcare advocacy and for the Tennessee Department of Commerce and Insurance.


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