ONCOLOGY & BIOTECH NEWS – November 2010 Issue
OP-ED By Eduardo Beruff
Nowhere today is there a greater need for a unified solution to improve access to care, patient outcomes, and cost-efficiency than in cancer care. Comprising hundreds of different diseases with thousands of therapeutic choices, cancer seems to defy a simple solution to address its complexity and costs. As experts of varying perspectives search for methods to address this challenge, it has become clear that an effective solution will require improved partnership and communication among all participants in the cancer treatment process. The challenge lies in the development of innovative tools and the information systems necessary to facilitate this alignment.
The challenges of cancer treatment are compounded by a variety of factors—some positive, many negative—that appear to place a universal solution further out of reach. These include the pace of development of cancer drugs; the gap between academic centers and community oncologists in accessing information and innovation; and the current managed care environment—particularly, the growing role of payers in driving treatment choices and reimbursement. In addition to these trends, the projected increase in the need for cancer care in the coming decade is expected to significantly outpace the growth of the oncology specialty, resulting in a potential shortfall of several thousand oncologists, according to an Association of American Medical Colleges Survey conducted by the American Society of Clinical Oncology.
As cancer costs steadily rise, driven in part by improvements such as better long-term survival and more patients entering the healthcare system, the increased administrative burden on oncology practices is forcing already-stretched oncologists to spend as much time securing reimbursement as they do learning about new treatments and caring for patients. A perfect distillation of the larger problems with healthcare in the United States, it is easy to assume that any attempt at a simple solution to cancer care would be more likely to contribute to the growing chaos than resolve it.
And yet, cancer arguably offers the greatest potential for the application of a single solution—not in the form of new medicines, procedures, or care models, but through information technology. Cancer care, after all, is a complex system that is increasingly data intensive and includes participants whose priorities and interests often seem at odds when it comes to treatment and payment decisions. Aligning the needs of all the parties involved in cancer care would relieve much of the administrative heavy lifting and redirect the focus towards what is best for the individual patient, while ensuring delivery of the best, most cost-efficient care.
We have already seen how this might work. In many cases today, cancer treatment decisions are made and implemented prior to securing approval from a patient’s health insurance carrier, leading to delays and denials of reimbursement if the insurance company does not agree with the treatment plan. Strides have been made to avoid these issues by having treatment plans reviewed by third-party experts or by formalizing pre-approved, evidence-based treatment plans for common cancers, sometimes called pathways. These standardized treatment regimens can help to ensure that the patient receives quality treatment that is covered by insurance while managing costs.
While these have been important steps in the right direction, there remains a need to further evolve this approach, as these treatment guidelines are rarely developed independently of the hospitals, pharmacies, physician networks, or managed care companies that use them. This approach also typically does not include an option to step outside of the pathway for patients who require an individualized treatment plan or provide the ability to secure reimbursement for patient participation in appropriate clinical trials. In addition, many pathways use limited data sources to create treatment recommendations, resulting in care choices that may not include all accepted treatment options or recent clinical advances.
Clearly, a system is needed to align the priorities of all participants in the cancer care continuum. It needs to be independent, unbiased, and accessible, providing comprehensive information on evidence-based treatment standards. The system should support and guide, rather than dictate, clinical decision-making. It should also incorporate a process that enables payers and clinicians to reach a consensus about care and reimbursement before initiating treatment, preventing possible conflicts. This innovative, collaborative approach would help streamline the reimbursement process, increasing efficiency and reducing costs while still ensuring that patients consistently receive quality care from the outset.
For such a system to be effective, it must be used consistently. In our company’s efforts to develop eviti™, a new Web-based application that serves as an oncology decision support tool, we sought to incorporate elements that would make the system indispensible to physician users. We included a library of over 1,400 evidence-based treatment modalities for more than 120 cancer types, input plan language for each participating insurance company’s providers, and provided access to available clinical trial protocols. We also added a mechanism that allows physicians to negotiate with payers regarding treatments that fall outside a coverage plan, when necessary.
Oncologists looking for a system to help them optimize care for their patients while meeting the growing call from insurers to adhere to professional guidelines and minimize costs should ensure that any system being considered contains all the necessary components to accomplish these goals. They should also look at how often the system is updated, how many and which insurers participate, what steps the technology provider has taken to protect patient data and comply with privacy laws, and how easy the system is to use and access. Once the system is in place, practices need to periodically assess whether it has measurably contributed to improving patient outcomes, which remains the most important objective.
Eduardo Beruff is CEO and president of eviti, Inc. in Philadelphia, Pennsylvania (www.eviti.com). Oncology & Biotech News has not received nor requested any consideration from eviti, Inc. for publishing this editorial.