Abstract: eviCore healthcare uses the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines®) to support its proprietary program for medical oncology drug management. The purpose of this study was to evaluate the pattern of NCCN adherence during the first year following program launch in regional payer markets. NCCN adherence rate was calculated using authorization requests submitted in month 1 and month 12 following program launch for four regional, third-party payers representing 13 different states. Weighted averages were applied to account for volume differences by market. The rate of NCCN adherence increased for each health plan during the first program year, ranging from 69% to 84% in month 1, rising to 79% to 91% in month 12. The weighted cumulative NCCN adherence during month 1 for all included plans was 75% and rose to 88% at month 12 following program launch.
Over the past decade cancer treatment has evolved at an extremely rapid pace. Advances through clinical research coupled with accelerated Food and Drug Administration approvals have led to nearly continuous changes to recommended treatment standards. In 2018 alone, the National Comprehensive Cancer Network (NCCN) made over 150 updates to their published cancer guidelines and compendia.1,2 Such a dynamic environment reinforces the need for highly accurate clinical decision support tools to assist practicing physicians in effectively utilizing the latest evidence-based treatment guidelines. eviCore healthcare has a proprietary clinical decision support program, originally initiated in 2014, that uses the NCCN guidelines to facilitate management of medical oncology drug utilization.
A study was conducted to evaluate the pattern of NCCN adherence in regional payer markets during the first year following the launch of eviCore’s Medical Oncology clinical decision support program.
Methods
The eviCore decision support program is accessed through a web-based portal without any technical implementation required by the provider or medical facility. eviCore is fully delegated to conduct a prior authorization review of an entire treatment regimen. Without any additional effort by the prescribing physician, an electronic transmission is sent over to the health plan and/or the pharmacy benefit manager respective of the medical or pharmacy benefit coverage of each drug within the regimen-based authorization.
All cancer drug treatment authorization requests submitted in month 1 and month 12 following program launch for four regional, third-party payers representing 13 different states were included. With each payer having varying start dates, the total time period represented in data is from June 2015 to October 2018. All four payers had utilization management of high-cost oncology drugs in place prior to eviCore program launch.
All treatment regimens assigned NCCN Category of Evidence 1, 2A, or 2B are considered NCCN-adherent treatment selections. NCCN adherence was assigned based on the results of the clinical decision support and peer-consultation processes utilized by eviCore to adjudicate the treatment request. NCCN adherence rate was calculated for each subgroup and a cumulative NCCN adherence rate for all included cases was calculated using weighted average accounting for volume differences by market.
Due to limitations of evaluating NCCN adherence in claims data available before program launch, month 1 post-launch data was used as a surrogate for pre-program NCCN adherence. Requests with incomplete clinical data were excluded from analysis. Included requests were stratified by month 1 or month 12 from initial program launch date for each health plan.
Results
There were 2028 treatment regimen requests that were fully evaluable, with 1285 occurring in month 1 and 743 occurring in month 12 following program launch. The rate of NCCN adherence increased for each health plan during the first program year, ranging from 69% to 84% in month 1 and rising to 79% to 91% in month 12 (Figure 1). The weighted cumulative NCCN adherence during month 1 for all included plans was 80% and rose to 88% at month 12 following program launch. Month 24 data was available for only one plan in the study. The NCCN adherence rate continued to rise from 79% at month 12 to 86% at month 24 post-program launch.
Discussion
Cancer treatment is evolving, and many therapeutic options are available at very high costs, making them a prime target for utilization management. A variety of provider- and payer-based utilization strategies have been deployed over the years with varying outcomes. Most payers have implemented single-drug prior authorization requirements while others have incented providers to use clinical pathways. This study shows that clinical decision support supplemented by peer consultation is an effective means of increasing oncologists’ adherence to NCCN-recommended therapies across a broad range of regional provider markets.
The adherence impact demonstrated in this study is a rather conservative estimate because month 1 post-launch data was used as the surrogate for the pre-program NCCN baseline adherence measurement. There was an impact on therapies being initiated immediately after the program went into effect, making the surrogate an overestimate for pre-program adherence. A published study by Newcomer et al, using this same decision support model, demonstrated improved guideline adherence as well as a decrease in overall drug treatment spend.3 The research presented in this manuscript was not designed to measure the impact of NCCN adherence on spend. However, based on other published literature, it is reasonable to project that payers deploying this clinical decision support model will yield similar results.
Drug cost is largely contributing to the growing cancer cost trends as nearly all oncology drugs that enter the market have price tags of over $100,000 per patient per year. Adhering to NCCN guidelines ensures appropriate use of these costly therapies and drives down spend on therapies that are not proven effective or are unsafe. A recent study found that patients on Medicare with metastatic breast cancer who receive treatment that is discordant with NCCN guidelines assumed higher out-of-pocket expenses compared with those who do get treated according to guidelines.4
High NCCN guideline adherence is a goal of the program, however, achieving 100% adherence is not an expectation. While the majority of patients are best served by following a regimen recommended by NCCN, there are individual patient scenarios that fall outside of the clinical conditions covered specifically by the guidelines. The American Society of Clinical Oncology (ASCO) recommends that all individuals have full access to the anticancer therapy most appropriate for their disease, according to the most current scientific evidence.5 A critical feature for any guideline-based utilization management tool is to include a rapid yet thorough review process to evaluate these clinically appropriate exceptions to guideline recommendations.
Decision support programs (like the one used in this study) have demonstrated the ability to have a positive impact on provider evidence-based prescribing patterns. As the number of unique drug treatment options continues to grow and the cost of each new option continues to rise, identifying treatment options that are high value becomes increasingly important. Multiple stakeholders will be relied upon to incorporate meaningful value assessments into the equation when making cancer treatment recommendations within the menu of options endorsed by nationally recognized guidelines. First-generation tools such as the NCCN Evidence Blocks and ASCO Value Framework have been developed to support clinical decisions about value and can be used to facilitate discussions between physicians and patients regarding the merits of each choice for cancer drug treatment. These value tools, while useful in their defined setting, are not designed or validated to support broad policy assessments regarding optimal, high-value treatment options. Recently, NCCN has taken another step into value assessment by incorporating Categories of Preference within the various guidelines to indicate regimens that are preferred by the panel due to superior efficacy, safety, and/or affordability.
Conclusion
The results of this study indicate that decision support methodology enhanced by peer consultation can be applied to better direct providers and patients toward guideline-recommended treatments. Further research is necessary to determine if value considerations will be well received by prescribing physicians when considering drug treatment decisions with cancer patients.
References
1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) © National Comprehensive Cancer Network, Inc. 2019. https://www.nccn.org/professionals/physician_gls/default.aspx. Accessed January 27, 2020.
2. Referenced with permission from the NCCN Drugs & Biologics Compendium (NCCN Compendium®) © National Comprehensive Cancer Network, Inc. 2019. https://www.nccn.org/professionals/drug_compendium/default.aspx. ccessed January 27, 2020.
3. Newcomer LN, Weininger R, Carlson RW. Transforming prior authorization to decision support. J Oncol Pract. 2017;13(1):e57-e61. doi:10.1200/JOP.2016.015198
4. Phillips C, Azuero A, Kenzik KM, et al. Guideline discordance and patient cost responsibility in Medicare beneficiaries with metastatic breast cancer. J Natl Compr Canc Netw. 2019;17(10). doi:10.6004/jnccn.2019.7316
5. American Society of Clinical Oncology. Policy Statement on the Impact of Utilization Management Policies for Cancer Drug Therapies. J Oncol Pract. 2017;13(11):758-762. doi:10.1200/JOP.2017.024273
