ASCO Opposes Payer Utilization Management Approaches that Curb Access to High-Quality, High-Value Cancer Care

ASCO Policy Statement Points to High-Quality Clinical Pathways as Appropriate Utilization Management Strategy for Cancer Drug Treatments
April 18, 2017

The American Society of Clinical Oncology (ASCO) opposes payer-imposed utilization management policies that restrict patient access to high-quality, high-value cancer care. In a statement released today, ASCO asserts that in modern cancer care there is frequently a lack of interchangeable clinical options, and that optimal cancer care requires patient access to the most medically appropriate drug at the most opportune time based on the highest quality evidence. For this reason, according to ASCO, high-quality clinical pathways are payers' best first option to ensure appropriate utilization of anti-cancer drugs and the delivery of high-quality, high-value care yielding optimal benefits and outcomes.

The American Society of Clinical Oncology Policy Statement on the Impact of Utilization Management Policies for Cancer Drug Therapies reviews current utilization management policies that public and private insurers use to control the use of anti-cancer drug therapies, including prior authorization requirements, restrictive formularies, step therapy (fail-first requirements), and specialty specific tiers. In the statement, ASCO also recommends ways to ensure these policies promote rather than hinder patient access to high-quality, high-value cancer care. 

"Utilization management strategies, when implemented without appropriate patient safeguards, can impede patient access to high-value, clinically appropriate care," said ASCO President Daniel F. Hayes, MD, FASCO, FACP. "Payer policies must reflect the current requirements of contemporary cancer care and be evidence-based on what constitutes high-quality care."

The ASCO statement also establishes a framework for evaluating the impact of coverage or utilization management strategies on the care of patients with cancer:

  • 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.
  • Utilization management policies should be evidence-based and reflect the most current science and understanding of cancer treatment.
  • 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.
  • Payers should implement utilization management policies in a way that minimizes administrative burdens–specifically time and effort–on both providers and patients.

Clinical Pathways: Appropriate Utilization Management Policy When Patient Safeguards in Place

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 believes that well-designed, high-quality clinical pathways should be the first choice of payers to ensure appropriate utilization of anti-cancer drugs and the delivery of high-value care.

Clinical pathways, when appropriately designed and implemented, are evidence-based treatment management tools used to deliver high-quality cancer care for specific patient presentations. Payers, institutions, and clinicians use pathways to reduce variabilities in treating specific conditions and control costs, with evidence suggesting that well-designed clinical pathways could address the cost of cancer care without compromising patient access to medically appropriate treatments, even when the cost is high.

Concerns have been raised that not all clinical pathways in oncology have been developed and implemented in a high-quality, transparent, and efficient way. Furthermore, the proliferation of clinical pathways has created an overwhelming and counterproductive administrative burden for many oncology providers. Patients with identical clinical characteristics treated by a single clinician can be on different pathways, based solely on the payer, leading to differences in treatment and related administrative complexity that may represent obstacles to quality and efficiency within a practice.  

The potential promises and perils of oncology pathways led ASCO to release its "Criteria for High-Quality Clinical Pathways in Oncology," in November 2016 to guide pathway implementation, use, and analysis.

The full statement is available now.     

 

 

ASCO in Action logo