Prior Authorization Pilot Reduced Health Plan's Cancer Drug Costs by 20%

Including a real-time decision support tool in the prior authorization process significantly reduced the cost of therapy for UnitedHealthcare, while complying with nationally accepted guidelines established by the National Comprehensive Cancer Network (NCCN).

The NCCN Clinical Practice Guidelines in Oncology informed the content of a real-time decision support tool that was included in a computer-based prior authorization system. The online tool was developed by eviCore healthcare, a company that manages UnitedHealthcare’s injectable chemotherapy program. Physicians submitted minimal clinical data to reach a treatment-decision node within the NCCN Guidelines. Physicians who selected one of the recommended treatments were granted immediate authorization.

“The program puts information at oncologists’ fingertips to help them ensure that their patients will be covered for proven cancer treatments that offer the greatest promise for survival and quality of life,” Lee Newcomer, MD, senior vice president of oncology at UnitedHealthcare, said in an associated press release. “The objective of the pilot was to ‘get to yes’ by offering all available evidence-based treatment options at decision time.”

The 1-year pilot, which was launched in a Florida commercial health plan, documented only 42 denials of the 4272 eligible cases that were reviewed as a part of the pilot. The chemotherapy drug costs for the prior authorization pilot were compared with similar time periods in the previous year for Florida. Costs in the southeast region of the country were used as the control. Of the cases that needed a peer-to-peer discussion, 95% were granted coverage approval for evidence-based chemotherapy in less than a 24-hour period. Authorization for only 1% of eligible cases was rejected.

At the end of the 1-year period, Florida saw a —9% change in cost, national costs increased by 10%, and southeast regions increased by 11%. The difference in the changes between the control regions and Florida translated into a $5.3 million savings for Florida during the 1-year period.

“Collaborative, evidence-based programs such as this create a win-win for patients, care providers and health plans. NCCN appreciates UnitedHealthcare’s creativity and willingness to explore a cost-effective approach to cancer treatment that enables care providers to select among the most appropriate Guidelines-based options for each patient,” Robert Carlson, chief executive officer of NCCN said in a statement.

Reference

Newcomer LN, Weininger R, and Carlson RW. Transforming prior authorization to decision support [published October 18, 2016]. J Oncol Pract. doi: 10.1200/JOP.2016.015198.