A New Prior Authorization Decision-Support Tool Can Reduce the Costs of Cancer Treatment

Dana Taylor

August 2017, Vol 7, No 8 - Reimbursement


Unless the costs of cancer care are reduced significantly, it is estimated that by 2028, the combination of patients’ health insurance premium costs plus out-of-pocket expenses will be the same as the average US household income. Cancer drug costs are escalating at an even faster rate, at least in part because of accelerated new approvals by the FDA and higher drug unit costs.

A recent study from UnitedHealthcare showed that a new prior authorization (PA) program that integrates real-time decision support can minimize authorization denials and lower the total cost of chemotherapy treatments using a digital system from eviCore.1

“It is essential that policymakers find methods to lower other costs to offset the financial burdens of newer and often more effective treatments,” noted Lee N. Newcomer, MD, MHA, Senior Vice President, Oncology and Genetics, UnitedHealthcare, and colleagues.1

Healthcare payers use the PA strategy as a way to control healthcare costs by ensuring accurate prescribing practices. Physicians often react negatively to the use of a PA, because it is time-consuming, at times confusing, and perceived as unnecessary.

The majority of oncologists believe that they are qualified to make clinical decisions for their patients on their own, without a PA mechanism, by following the medical literature and being up to date with current guidelines.

A 2011 survey of 103 health plans and 101 medical oncology practice administrators showed that only 18% of payers reported that they were able to reduce the inappropriate use of chemotherapy medications with PA.2

New Prior Authorization System

Before launching the computer-based PA system, UnitedHealthcare used the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium as the criterion for their PA guideline; although this was well-accepted, approximately 7% of chemotherapy drug claims were still rejected annually.

To reduce the denial rate and minimize drug costs, Dr Newcomer and colleagues introduced a new, computer-based PA system operated by eviCore and designed to minimize authorization denials by providing real-time decision support and offer alternative treatment options if the request did not comply with the NCCN guidelines.

The new PA system required information about the tumor type, tumor stage, genetic tests, drug combinations, and line of therapy. The system only asked for pertinent information to reach a treatment-decision node in the NCCN guidelines for the specific tumor type.

To receive approval for a PA, oncologists could select a therapy from the listed NCCN-recommended regimens. To minimize denials, all available recommended treatments were displayed for physician consideration and immediate authorization was granted for any NCCN-compliant selection.

However, the physician could also request a preferred treatment option by listing the desired drugs and the reason for the request. Published articles supporting the preferred treatment could also be submitted. The request was reviewed by an eviCore oncologist who authorized the request or initiated a peer-to-peer discussion.

“The concept design departed from traditional prior authorization. The system was intentionally built to find a solution for patients if one was available. Oncologists were shown all NCCN-recommended regimens for their patient’s specific clinical parameters at the time of the request; it was functioning as a decision-support tool,” said Dr Newcomer and colleagues.

Reduced Chemotherapy Drug Costs

UnitedHealthcare tested the new computer-based PA tool in a pilot program in Florida from June 2014 to June 2015. Overall, 6807 PA requests were processed in the system; of these, 2533 requests were withdrawn or expired. Of the remaining 4274 requests, 4211 were given authorization and 42 (1.0%) were denied. In addition, oncologists obtained immediate online approval for 2490 (58%) cases, without the need for further interaction with the health plan. Approval was granted for 95% of the remaining cases, which required further short-term interaction.

The researchers compared the costs of chemotherapy drugs in the PA pilot program with the costs of these therapies during the previous year for 3 geographical regions—the entire country except for Florida, the Southeast without Florida, and in Florida alone.

Chemotherapy drug rates vary from year to year and are affected primarily by the introduction of new drugs. As expected, the drug cost trend rates were similar for the regions before the introduction of the decision-support online tool, because all 3 regions were using the same claim review methods.

With the introduction of the new decision-support tool in Florida, however, the chemotherapy drug cost trend increased by 10% for the nation (without Florida) and by 11% for the Southeast region, whereas the trend in Florida decreased by 9%. Overall, a 20% difference was seen in drug costs for the pilot program in Florida compared with the rest of the country.

The difference between the national and regional increases and the Florida decrease in chemotherapy drug costs represented an annual savings of $5.3 million in Florida.

Dr Newcomer and colleagues “believe the additional review details of drug combinations and line of therapy, combined with offering an immediate NCCN-compliant alternative for the oncologist, are the key reasons for the difference in costs between Florida and the remainder of the nation.”

The use of this computer-based PA tool enabled the pilot program to reduce the cost of care by approximately $1.20 per member per month in UnitedHealthcare in Florida. “A sustained result such as this could fund several new drugs,” suggested Dr Newcomer and colleagues.

“This project provides evidence that it is possible to reduce the cost of cancer therapy using evidence-based decision making. Policymakers, payers, patients, and oncologists can all benefit from future strategies that divert funding from marginal therapies to more effective treatments,” Dr Newcomer and colleagues emphasized.


References

  1. Newcomer LN, Weininger R, Carlson RW. Transforming prior authorization to decision support. J Oncol Pract. 2017;13:e57-e61.
  2. Reinke T. Plans and oncologists don’t see eye to eye on prior authorization. Manag Care. 2011;20:14-16.