The escalating costs of cancer care combined with variations in concordance with evidence-based practice guidelines is putting the United States on a collision course for an impending collapse of its current health care system according to roundtable panelists at the NCCN 15th Annual Conference. Clifford Goodman, PhD, of The Lewin Group, led an engaging roundtable debating the utilization of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) and the impact of escalating health care costs.
“Our central question used to relate to how a potential therapy fared in a clinical trial, and now the question is ‘will it be reimbursed?’ It’s not intended to suppress innovation, but rather direct it”
Dr. Goodman began the session by questioning the panelists on how the NCCN Guidelines™ were being used and their appropriate role.
Aetna Inc. spends upwards of $1.5 billion a year on cancer care and use the NCCN Guidelines as part of its care decisions as well as reimbursement methodology, noted James D. Cross, MD, of Aetna Inc. “It’s extraordinarily rare that treatment is denied by Aetna in a life-threatening illness,” he noted.
Lee N. Newcomer, MD, of UnitedHealthcare stated that United spends $3 billion annually on cancer care and also utilizes the NCCN Guidelines and NCCN Drugs & Biologics Compendium (NCCN Compendium™) to make coverage decisions.
“We recently launched a new program that combines clinical and claims data to gauge physicians’ rate of compliance with the NCCN Guidelines,” Dr. Newcomer added. “Reports are sent to the physicians that include their compliance rates as well as information about their patients including if they are filling their prescriptions.”
Dr. Newcomer stated that the data should be used as a quality improvement method and not to judge physicians.
In addition to physicians, patients need to be aware of evidence-based guidelines and their role in coverage determinations stated Nancy Davenport-Ennis, of the National Patient Advocate Foundation.
“In the last 14 years, our organization has closed more than 500,000 cases and the NCCN Guidelines are often used by our case managers to fight and win appeals,” said Davenport-Ennis. “Patients should be encouraged to enter into a dialogue with their physicians about the cost implications of treatment and how it relates to the type of insurance they have. Their main concern is what is the best intervention for me and how do I know if it’s the best. The NCCN Guidelines provide a third party authorization of the treatment their physician is recommending.”
Following evidence-based practice guidelines can also have an effect on the overall cost of treatment as Dr. Cross described a recent article that Aetna published finding that overall care was 35 percent less expensive if treatment guidelines were followed.
“This further demonstrates the reach that evidence-based guidelines have and can be looked upon as the commonality that brings patients, physicians, and insurers together,” said Dr. Cross.
Physicians adherence to guidelines is still an evolutionary process noted Al B. Benson III, MD, of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, but he sees them permeating across the medical enterprise.
“I’ve seen notes embedded into reports or on letterhead from other physicians stating that they follow the NCCN Guidelines,” said Dr. Benson. “I believe we’ll continue to see instances like this especially as we instill the importance of the NCCN Guidelines into residency and fellowship programs.”
The NCCN Guidelines are certainly being used across various applications Dr. Goodman noted, but questioned the panelists on what they do when they’ve exhausted all options in the guideline and how these decisions impact cost.
Dr. Benson stated that referral to a clinical trial is usually the recommendation, but the challenge lies in finding an appropriate trial that is enrolling for each patient.
Although the end of a cancer patient’s life is often thought to be the most expensive, when desperation may set in and patients may be willing to try anything with potential benefit, Dr. Newcomer noted a report that debunked the concept.
“We recently analyzed data and found that the costs actually remained constant from month to month, with the exception being in leukemia and lymphoma cases. The highest expenditures were hospitalizations related to complications from the disease,” said Dr. Newcomer.