Key Clinical Summary

• Oncology spend continues to rise, driven by increased US Food and Drug Administration (FDA) approvals, combination regimens, and expanded indications for therapies such as checkpoint inhibitors.
• Gaps in utilization management (UM)—especially across medical and pharmacy benefits—can lead to inefficiencies, safety risks, and higher total cost of care.
• Emerging innovations in precision medicine, cell and gene therapy, and molecular diagnostics require specialized, oncology-focused review models and value-based care approaches.

At a panel session at the 2026 Academy of Managed Care Pharmacy (AMCP) conference, speakers underscored how accelerating innovation in oncology—marked by increasingly complex, high-cost therapies—is outpacing existing payer management models, highlighting the need for more integrated, evidence-based approaches to balance clinical outcomes with sustainable cost control.

Evolving Oncology Cost Drivers and Treatment Complexity

Speakers Adam Hoye-Simek, PharmD, RPh; Beth Isaac, PharmD; and Kelly Romo, PharmD, BCOP, described oncology as the fastest-growing category of medical and pharmacy spend, with costs accounting for up to 50% to 60% of total cancer expenditures. They noted that 54 new oncology drugs were approved by the FDA in 2025 alone, reflecting a rapidly expanding pipeline.

Key cost drivers include longer treatment durations, earlier use of high-cost therapies, and increasing reliance on combination regimens. For example, immunotherapy agents such as pembrolizumab continue to expand across multiple indications, contributing significantly to payer burden.

The session highlighted structural gaps in utilization management, particularly when medical and pharmacy benefits are reviewed separately. This fragmented approach can result in overlapping toxicities, suboptimal sequencing, and increased costs. Speakers emphasized the importance of protocol-level review and cross-benefit coordination to ensure appropriate therapy selection.

Cell and gene therapies were identified as a major challenge, with total treatment costs approaching $1 million per patient. Authorization requests for chimeric antigen receptor (CAR) T therapies increased by nearly 50% year-over-year, while other advanced therapies saw growth exceeding 100%. These trends are prompting payers to consider preferred product strategies and enhanced clinical oversight.

In precision medicine, next-generation sequencing (NGS) and circulating tumor DNA (ctDNA) testing are becoming integral to care. However, inconsistent coverage policies and prior authorization gaps can lead to access issues and administrative burden. Molecular residual disease (MRD) testing is also emerging as a prognostic tool, though coverage remains variable.

Expert Insights on Utilization Management and Value-Based Care

According to Dr Hoye-Simek, oncology management must shift toward treating the right patient with the right drug at the right time, emphasizing proper sequencing and biomarker-driven decision-making.

Dr Isaac highlighted that fragmented UM processes create inefficiencies and negatively impact both provider experience and patient outcomes. She noted that oncology-certified reviewers—such as board-certified oncology pharmacists and oncologists—can improve peer-to-peer discussions and facilitate evidence-based decisions.

Dr Romo emphasized the growing role of value-based care models, citing estimates that up to $60 billion in oncology spending could be optimized annually through value-based specialty care. She also discussed “soft steer” programs, which guide providers toward lower-cost, clinically equivalent therapies without mandating step therapy, thereby balancing cost control with provider autonomy.

Panelists agreed that collaboration among payers, providers, and oncology specialists is essential to address rising costs while maintaining high-quality care.

Strategic Implications for Payers and Managed Care

For payers and managed care organizations, the session underscores the need for integrated, cross-benefit oncology management strategies. Incorporating oncology-specific expertise, adopting value-based care models, and leveraging precision medicine tools can improve clinical outcomes while controlling costs. Enhanced coordination and proactive policy updates are critical as the oncology landscape continues to evolve.

Future Directions in Oncology Management and Policy

As oncology innovation accelerates, traditional management approaches are no longer sufficient. Future success will depend on holistic, value-driven strategies, improved utilization management, and stronger collaboration across stakeholders to ensure sustainable, high-quality cancer care.

Reference

Hoye-Simek A, Isaac B, Romo K. Mind the Gap: Rethinking Oncology Management Before It’s Too Late. Presented at: AMCP 2026; April 13-15; Nashville, TN.