In 2018, the American Society of Clinical Oncology (ASCO) conducted a ‘State of Oncology Practice’ survey aimed at identifying the largest pressures facing oncologists.[1] Despite being exposed to more death and grieving than most other physicians and also having one of the most severe burnout rankings; the number one issue oncologists identified was payer pressure.[2][3] When payer pressure was analyzed, the top two issues were prior authorization followed by coverage denials and/or appeals.[1]

What is it about the prior authorization process that is a cause of so much concern for oncologists? It turns out to not be one single issue, but rather a mixture of clinical, operational, and financial aspects.

Clinically, oncologists are frustrated that a health plan’s coverage criteria, which is used to make medical determinations, may be at odds with the most recent clinical guidelines and expert consensus.[4] When this happens, the oncologist will often have to wait on hold with the health plan to explain their rationale for the decision, which requires precious time and office resources.[4]

Despite their frustration, oncologists recognize the need for prior authorization, especially with all the advancements in cancer treatment in the last decade.[4] Health plans also recognize the need for prior authorization in oncology drug management given the number of new therapies, the costs of these therapies and the fact that members are living longer with cancer. So, the challenge for health plans is this: How do you keep your physician networks intact using oncology utilization management?

Keep Intact with Oncology Analytics
Oncology Analytics is a different kind of partner for oncology drug utilization management. We only employ board-certified medical oncologists, hematologists and radiation oncologists, assuring your providers will speak to a true peer when discussing a member’s care. We can provide your health plan with real-time oncology expertise as an extension of your internal teams, for a fraction of the cost of doing it yourself. We are experts in oncology medical and pharmacy benefits as they relate to cancer drugs.

A cohort of 17 organizations, including ASCO and the American Medical Association (AMA), suggested areas of improvement for prior authorization focused on five different categories: clinical validity, continuity of care, transparency and fairness, timely access and administrative efficiency, and alternatives and exemptions.[5]

Oncology Analytics has solutions in place for each of these categories:

Clinical Validity
Oncology Analytics’ treatment determinations are based on FDA approvals, oncology compendium, and peer-reviewed journals using the Centers for Medicare & Medicaid Services (CMS) coverage rules. We do not artificially limit access to oncology drugs through a pathway process.

Each review is evaluated on the above criteria using a patient-first approach that balances the specific clinical need of each patient against comorbidities, toxicities, and cost.

Continuity of Care
Patients already established on effective care are able to continue this therapy.

Transparency and Fairness
Our coverage criteria are readily available, and any request that does not meet medical necessity is personally communicated to the office before rendering a decision, offering the opportunity to collaborate with the oncologist and improve patient coordination.

Timely Access and Administrative Efficiency
Oncology Analytics provides a state-of-the-art, easy to navigate e-Prior Authorization portal as a key component of our prior authorization process, which enables both speed and efficiency. The e-Prior Authorization portal can be used by network providers standalone or integrated into a health plan’s existing portal via SSO. Our current provider satisfaction score for our e-Prior Authorization solution is over 95%.

Further, we exceed the CMS review timeframes for part B requests with an average expedited review of one hour nine minutes and standard requests of one hour thirty-one minutes.

Alternatives and Exemptions
Our review process does not require physician offices to fill out prior authorization forms; rather, Oncology Analytics facilitates the clinical review based on clinical documentation on the member that can be uploaded to our e-Prior Authorization portal. This improves our physician relationships, significantly reduces the administrative burden and enhances data collection for providers participating in pay-for-performance and/or shared risk programs. As a health plan, you have administrative views of all submitted oncology prior authorization cases with real-time information.

Oncology Analytics understands the complexity involved in the management of cancer treatment options caused by the rapid pace of research and new drug introductions that are changing the oncology landscape daily. We are committed to the ongoing review and analysis of oncology treatments, their outcomes, and adverse effects to ensure that all cancer treatment recommendations provide the patient with the opportunity to achieve the best possible outcome.

If you would like to contact one of our oncology specialists to discuss strategies to help your organization Keep Pace with new and emerging cancer treatments, please click here.

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[1] Kirkwood, M. K., Hanley, A., Bruinooge, S. S., Garrett-Mayer, E., Levit, L. A., Schenkel, C., . . . Schlisky, R. L. (2018, July). The State of Oncology Practice in America, 2018: Results of the ASCO Practice Census Survey. Journal of Oncology Practice, 14(7), e412-e420.

[2] Managing Stress and Burnout in Oncology. (2006, May). Journal of Oncology Practice, 2(3), 130-131.

[3] The most burned out (and happiest) doctors, according to Medscape. (2017, January 13). Retrieved from https://www.advisory.com/daily-briefing/2017/01/13/burnt-out-doctors

[4] Lin, N. U., Bichkoff, H., & Hassett, M. J. (2018). Increasing Burden of Prior Authorizations in the Delivery of Oncology Care in the United States. Journal of Oncology Practice, 14(9), 525-529.

[5] Prior Authorization and Utilization Management Reform Principles. (2017). Retrieved from https://www.ama-assn.org/system/files/2019-06/principles-with-signatory-page-for-slsc.pdf

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