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Underwriting and Claims

The C-words: Cancer, Costs and the Case for Dedicated Case Management

Rose holding hands long

The diagnosis is still so frightening that many avoid uttering its name, resorting instead to euphemisms such as the “C-word” or the “Big C.” But cancer is less menacing than ever thanks to an arsenal of new drugs and medical discoveries – particularly when treatment is coordinated by an effective case manager.

Proactive health plans are turning to nurse case managers to offer their members vital cancer treatment support and to help navigate associated medical, emotional, and financial challenges. Such expertise is increasingly essential: each year, $895 billion is spent on cancer specialties, therapies, and technologies – more than any other disease, according to the American Institute of Cancer Research (AICR).

Specialized oncology case management programs are helping to manage these costs. Some have reduced hospital days by 50% or more, largely through effective interventions that help cancer patients overcome barriers to care, control symptoms, and adhere to treatment plans focused on achieving and sustaining remission.

RGA asked Melinda Baxter of ROSE® (Reinsurance Outcomes and Service Experts), the reinsurance industry’s premier medical and claim consulting program, to explain why oncology case management is so effective.


How does case management start?

It starts with an assessment. Nothing is taken for granted. Cancer is a complex diagnosis, and treatment can be lengthy, complicated, and sometimes debilitating. It is not realistic to expect a patient to navigate this landscape alone. Oncology case managers look at medical needs, as well as social and functional considerations. This way, we can guide patients through treatment plans tailored to their specific situations and overcome barriers to care.

There is much discussion about empowering the patient to make informed decisions. What does this mean – particularly with a cancer diagnosis?

Determining a course of cancer treatment presents a difficult challenge for many of the newly diagnosed. Options vary, based on the cancer sub-type, the disease stage, and other factors. It's easy for a patient to become bewildered by the many headlines about medical advances – in many cases, these offer more hype than hope. Case managers can help patients evaluate the options and find the most effective therapies and healthcare providers.

Are case managers advocates for patients or insurers?

All patients have fundamental healthcare rights related to protecting privacy, seeking a second opinion, making informed treatment decisions, and accessing personal medical records. Case managers are the chief advocates for these rights. Our most important task is to construct a customized care plan to improve the patient’s quality of life. We work with patients to identify which symptoms and side effects are causing the most distress and then design specific interventions to alleviate suffering. Ultimately, both the patient and payor benefit with a better clinical outcome.

More of us are surviving with cancer than ever before. Clearly, case managers can help guide the patient into remission ... but then what?

Case managers help people live with cancer. Most cancer patients survive beyond the initial acute treatment phase, but care does not stop after these initial treatments end. Patients receive ongoing monitoring, assessment, and treatment for cancer and its late medical effects. Every patient will experience at least one transition from acute treatment to maintenance, survivorship, palliative care, or hospice. Many patients will struggle with these transitions. For some, cancer will return. Case managers can improve the transition to life after cancer – or to a new treatment regimen.

We’re hearing about the rise of precision cancer treatments and customized care. There are claims of dramatic improvement in survival rates for some cancers. What does this mean for the future of case management in oncology?

There was a time when oncologists took a one-size-fits-all approach to patients. Those days are over. Today's individually tailored therapies have fewer side effects, and some are available in oral form, requiring fewer trips to the oncology infusion center. But some of these cancer therapies are far more expensive than previous treatments, and may not always be effective. Other drugs are still undergoing clinical trials. Because these therapies have not yet received U.S. FDA (Food and Drug Administration) approval, they can present special risks.

The case manager serves two vital roles: one as an advocate, protecting patients from unscrupulous operators and ensuring that patients enroll in reputable and approved clinical trials, and two, as an educator, educating patients about emerging therapies and clinical research trials. 


Want to learn more? RGA’s ROSE Program’s Oncology Case Management Guidelines were created specifically for health plan case managers to help guide cancer patients through their treatment journey. The guidelines cover five essential aspects of effective oncology case management, and each section has an accompanying on-demand web module to provide case managers with more in-depth information, strategies, and patient resources. Contact us to discuss the guidelines and other value-added services from RGA.

 

The Author

  • Melinda Baxter
    RN, MSN, CCM
    Senior Health Services Consultant
    ROSE® Program