Cancer specialists have issued a policy paper arguing that insurers must put the patient first when it comes to reviewing the care recommended by doctors.
The American Society of Clinical Oncology believes it is the right time to remind insurers and policymakers that utilization management tools be used in the right way.
Dr. Debra Patt, chair of ASCO’s Clinical Practice Committee and vice president of Austin-based Texas Oncology, said cancer care costs are increasing at a rapid rate.
In tandem with those increases, insurers are more frequently using utilization management tools such as prior authorization for treatments and step therapy, where insurers insist on certain drugs and procedures before others are tried.
The society, which published the policy paper, believes insurers and policymakers have to be reminded that cost cannot be used to delay treatment for cancer sufferers.
Prior authorization is a major issue when it comes to the treatment of cancer, Patt said.
"Our concern is that utilization management is causing more and more treatment to be delayed," Patt told Patient Daily.
When some medications can cost, for example, $10,000, it is appropriate to try to make sure costs are kept down, Patt said. "Utilization management is appropriate but our concern is that specialists decide should what treatment is appropriate."
Often, doctors will make a clinical decision and change the dose of a medication based on an individual's unique situation, including whether they are suffering from another condition.
But that may not line up immediately with the insurance company's utilization schedule, leading to the potential that treatment may be delayed. In the past, treatment, including chemotherapy, may have been delayed one or two days, now it can be a week or more, Patt said.
ASCO's bottom line is that patients receive appropriate care, and that the specialist is in the best position to decide, Patt said.
The society supports the wide use of a decision tree with specific guidelines for treatment to make it easier for authorization reviewers to make quick decisions that will line up with those made by specialists. It wants evidence and value-based decisions to be made by reviewers based on recognized path ways.
"The rising cost of cancer care is a real and significant concern, but in ASCO's view, any strategies to address cost must first protect patient access to the most appropriate treatment for their situation and their disease, throughout the patient's clinical course,” ASCO said in a statement.
In its policy paper, ASCO argues that individuals with cancer should have full access to the anti-cancer therapy most appropriate for their disease when used in accordance with current clinical and scientific evidence. Cost should not be the primary driver of utilization management policies, the association said.
The paper further states that utilization management processes "should result in timely and clear determinations that are consistent with the health insurer's coverage and other policies."
Payer cost containment strategies and decision-making processes should be transparent and without conflicts of interest, and in a way that eases administrative burdens on providers and patients.