2024 Trends, Events, and Developments (TEDs) in the Payer World—Oncology

Welcome to the 2024 TEDs issue on Oncology! I am Cynthia Miller, MD, MPH, FACP; Vice President, Medical Director, Access Experience Team; and editor of All Access Newsletter. This edition focuses on the emerging trends in oncology occurring in various payer segments. Our expert ex-payers provide insights into these trends and developments and discuss how they foresee them impacting the health care system, especially patients, health systems, and the pharmaceutical industry.

Future of Research and Development in Oncology
Jennifer Williams, Vice President, Access Experience Team—PRECISIONvalue
Jenny writes about the future of oncology research and development in the post-IRA (Inflation Reduction Act) world. She discusses the importance of stakeholder collaboration, evidence generation, and new reimbursement strategies.

Care Pathways and Oncology Access
Christy Banach, Senior Director, Access Experience Team—PRECISIONvalue
Christy examines the role of care pathways in oncology. She explores the importance of pathways in maximizing patient outcomes and supporting value-based arrangements while she also describes some of the pitfalls. Finally, she discusses how manufacturers can support the development of care pathways.

Oncology Biosimilars
Molly Borchardt, Senior Director, Access Experience Team—PRECISIONvalue
Molly tackles the market dynamics of oncology biosimilars and pricing. She discusses the importance of launch pricing and contracting strategies to maintain profitability.

2024 Update on the Enhancing Oncology Model (EOM)
Janet Serluco, Senior Vice President, Access Experience Team, Oncology Lead—PRECISIONvalue
Janet provides an update on the Enhancing Oncology Model (EOM), particularly regarding enrollment rates, data sharing, and ways CMS is looking to increase participation. In addition, she explains how EOM’s focus on value-based care and evidence will have impacts on manufacturers not only for Medicare beneficiaries but potentially for commercial members as well.

We believe you will find this presentation of oncology trends and their impact on market access insightful as you navigate the payer landscape. As always, please feel free to drop me a note and let me know if you have a topic suggestion for the payer team to address, and we’ll do our best to cover it in a future edition.

Best Regards,

Cynthia Miller
VP, Medical Director
Experience Team


All Access is a bimonthly newsletter featuring key insights from our team of former payers intended specifically for market access leaders. It is published by PRECISIONvalue.

Guest Editor
Cynthia Miller

Andrew Cournoyer
Ryan Cox
Dan Danielson
Todd Edgar
Jorge Font
Dominic Galante
Ami Gopalan
Maureen Hennessey
Barbara Henry
Joe Honcz
Sejal Jonas
Kris Kang
Erin Lopata
Amy Martin
Ray Roth
Janet Serluco
Charline Shan
Jennifer Williams

Future of Research and Development in Oncology

In 2023 the FDA approved 55 novel therapeutics, the second highest count in the past 30 years. This included 16 oncology approvals, including 4 novel bispecific antibodies, which contain multiple sites for 2 different antigens. New oncology clinical trial starts are at historically high levels. The next-generation biopharmaceuticals pipeline is robust and full of promise for patients with cancer, with many CAR T-cell, NK-cell, and gene therapies and cancer vaccines in development.

Care Pathways and Oncology Access

The use of cancer care pathways aims to improve patient outcomes by prioritizing provider prescribing to high-value evidence-based treatments and therefore reduce the use of expensive therapies that could be more toxic and/or marginally effective. With the rapid development of new treatments in oncology, especially in targeted therapies and immunotherapy, and the increase in cancer care options, it can be difficult for oncologists to keep up with the evolution of prognosis, available medications, and their potential side effects. The addition of care pathways may be a way to provide physicians with a comprehensive and clinically relevant decision support tool.

Oncology Biosimilars

Biosimilars for oncology products and supportive agents have been on the market longer than any other class of biosimilars, with the first being a filgrastim biosimilar approved in 2015. There are now multiple biosimilars for filgrastim, pegfilgrastim, bevacizumab, trastuzumab, and rituximab. Payers have reported a significant decrease in cost per claim of oncology products that have biosimilars since 2019 with decreases in cost per claim between 33% and 39%. While oncology biosimilar uptake was initially slow, biosimilars for bevacizumab, trastuzumab, and rituximab now make up more than 73% of the market share through 2022.

2024 Update on the Enhancing Oncology Model (EOM)

One year after the end of the Center for Medicare and Medicaid Innovation’s multiyear Oncology Care Model (OCM), its successor program, the Enhancing Oncology Model (EOM), began on July 1, 2023. EOM is a voluntary 5-year model in which oncology practices assume risk and accountability for their Medicare patients’ health quality and total spend during 6-month episodes of care. Episodes begin with initiation of systemic chemotherapy for the 7 cancer types in which the Centers for Medicare and Medicaid Services (CMS) saw the greatest reductions in total episode payments under OCM: high-risk breast cancer; lung, prostate, and small intestine/colorectal cancer; lymphoma; chronic leukemia; and multiple myeloma.