Managed Care - April 2008 - (Page 30) UnitedHealthcare moves away from prior authorization nitedHealthcare, one of the nation’s largest managed care companies, is moving toward basing its coverage for outpatient chemotherapy drugs on the National Comprehensive Cancer Network Drugs and Biologics Compendium. The NCCN is an alliance of 21 major cancer centers around the country. The compendium is derived from its well-known NCCN Guidelines, treatment recommendations based on an independent evaluation of scientific evidence overlaid with the expert judgment of clinicians. The NCCN expects that the Centers for Medicare & Medicaid Services this summer will recog- U nize its compendium as an authorized source for Medicare coverage decisions. Also, the organization expects other private payers to adopt the NCCN compendium for their coverage policy. “We have collaborations with other major national payers in the works, so I would expect that the UnitedHealthcare step will be an impetus for other private payers to publicly endorse the use of our compendium,” says Bill McGivney, PhD, the NCCN’s chief executive officer. Like most private payers, UnitedHealthcare previously based its chemotherapy-drug policies on its own review of scientific literature. Lee N. Newcomer, MD, UnitedHealthcare’s senior vice president for oncology, says the new policy, which went into effect in March, transfers the decisions about chemotherapy coverage to the oncologists that determine the NCCN guidelines. An added benefit: Physicians — and patients, for that matter — can look up the NCCN guidelines instead of calling United to seek permission before proceeding with a test or therapy. “We’re not going to save a lot of money doing this, but what we will do is save everyone a lot of time,” he says. “People are on the phone for a long time, saying, “Is this covered or is it not covered?” They will be able to go to the Web site and find out in five seconds.” outcomes between that group and others around the country. “If there is a difference, we will share that difference with that group,” he says. “So they might get a retainer — the first time a breast cancer patient walks through the door they might get a $10,000 check for accepting the patient. We could just pay costs for drugs without hurting the doctors financially, and allow them to pick the drugs they think are most effective, and when there are multiple options they can select the most cost-effective.” The Zitter survey found that despite the increasing incidence of professional and other fees paid to oncologists by health plans, they are not completely replacing the revenue lost from moving to ASP pricing. But Newcomer says UnitedHealthcare, at least, does not aspire to reduce oncologists’ take-home pay. “I don’t think it makes any sense at all to try to reduce physician incomes right now,” he says. “What I pay the oncologist himself or herself is not what’s breaking the bank. It’s what they do with their pen that’s causing most of the escalating costs. With today’s incentives, they are encouraged to choose the treatment that is most expensive because they get their income from that.” Prior authorization is the main strategy used to ensure that oncologists are using the right treatment, but it might not work very well. Payers are “trying to figure out how they can apply their current tools — the things that are used in other categories — and that’s creating some trouble,” says Kirk McConnell, a Zitter analyst. “To a certain extent, they’re trying to nail a square peg into a round hole.” Although health plans report aggressive enforcement of prior authorization for specialty categories — most notably human growth hormones — enforcement is relatively weak for both oral cancer therapies and intravenous cancer treatments. A majority of health plans reported that fewer than 5 percent of PA requests are denied. The second most widely used management strategy — patient cost-sharing — may be maxed out, Dautel says. Both plans and oncologists said that copayments above $100 can prompt patients to look for alternative treatments. Nearly 30 percent of oncologists surveyed said more than 20 percent of patients forego treatment because of cost-sharing requirements. “This is a tool that we have pushed as far as we can,” Dautel says. Ironically, as their revenue has declined, oncologists have become more aggressive in collecting copayments. MC 30 MANAGED CARE / APRIL 2008
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