Colorectal cancer: complexities and challenges in managed care.

Background: Managed care weighs advances and associated costs to determine whether the combination of longer life at sometimes significantly increased cost represents value. The price of treatment is only 1 factor.

Objective: To review treatment decision processes for oncologic agents in managed care environments.

Summary: Price can be exceptionally high for individuals. But if the population size is low, the per-member-per-month (PMPM) impact can be almost negligible, unlike treatments that have moderate costs but are used ubiquitously. Cancer therapies have, for the most part, escaped managed care's notice. For 2007, the national Cancer Institute projects that antineoplastic agents will consume almost a quarter of the overall drug spend. The Medicare population is a unique concern with regard to cancer. Traditionally, Medicare reimbursement of chemotherapeutic agents was based on average wholesale price (AWP) discounting, not the oncologist's purchasing cost. This allowed oncologists to use reimbursement for infusions to support their medical practices. The proposed plan of the Center for Medicare & Medicaid Services (CMS) to use average sales price (ASP) plus 6% to reimburse for drugs used in the office setting leads to significant problems. Pharmacy and therapeutics committees will also face challenges: fewer data are available for some agents because they have become available through the U.S. Food and drug administration's Fast Track, Priority review, or accelerated approval processes.

Conclusion: Oncology disease management programs must reach out to patients and not necessarily deal with oncology issues directly, but address tangential issues that impact care, especially depression and pain management.