Health Plans | Utilization Management Medical Oncology

As the population ages, an increase of new cancer cases are expected to be diagnosed. The number of patients undergoing active treatment for cancer has never been higher, the complexity of therapy options is proliferating, and patients are being treated for longer periods of time. Unfortunately, many medical oncology patients do not receive a treatment plan consistent with current medical evidence, primarily due to:

• Drug use beyond the recommended lines of therapy
• Inappropriate drug combinations within a treatment regime
• Genetic testing not performed when indicated
• Administration of highly toxic drugs to patients with poor performance status.

Established in 2007, our Medical Oncology solution operates in all 50 states and supports Commercial, Medicare, and Medicaid members. We use clinical guidelines from the NCCN^®, a not-for-profit alliance of 28 leading U.S. cancer centers, to ensure that each unique patient receives the correct treatment regimen. The foundation of our collaboration with the NCCN is our mutual dedication to improving and facilitating the quality, effectiveness, efficiency, and accessibility of cancer care so that patients live better lives.

Our solution manages all cancer types, including those rare cancers that the NCCN Guidelines® do not cover. For these, our board-certified medical oncologists use up-to-date medical literature and the recommendations of medical specialty societies to ensure that all cancer patients receive evidence-based treatment plans.

eviCore’s Medical Oncology solution ensures that patients receive the correct treatment regimens. Our solution is not designed to deny care, but rather to direct oncology physicians to the best treatment options for each patient, based on their unique diagnosis, medical history, pathology, genomics, prior therapy, functional status, and disease severity.

Our medical directors are all board-certified medical oncologists and hematologists with experience in the development and use of clinical guidelines in community and academic practice settings. Our pharmacy specialists are doctors of pharmacy with residencies and experience in the development and use of evidence-based criteria and guidelines. In addition, we employ medical geneticists, pathologists, oncology nurses, and genetic counselors who contribute to holistic patient care and the maintenance of tested evidence-based clinical policies.

Our medical oncology solution is organized around the patient’s entire drug treatment plan rather than a request for a specific drug. Other vendor solutions are designed to process requests for approval of a single therapeutic agent and do not consider all clinically relevant patient information necessary to determine the most appropriate group of therapeutic and supportive medicines, commonly referred to as treatment regimens. Among other patient-specific factors, our evidence-based medical oncology solution takes into account:

• Diagnosis
• Stage of disease
• Clinical presentation
• Histopathology
• Comorbidities
• Patient risk factors
• Performance status
• Genetic or molecular alterations
• Previous treatment

Using clinical details that our clinical decision support application dynamically selects for each unique patient, we guide oncology physicians to the most appropriate treatment regimen(s), which often consist of a combination of therapeutic and supportive medicines. Once selected, eviCore issues approval to the provider and seamlessly communicates the medical benefit authorization to the health plan and the pharmacy authorization to the health plan’s pharmacy benefit manager.

If the provider selects a treatment regimen not supported by the NCCN^® or eviCore clinical guidelines, eviCore prompts the provider to build a customized treatment regimen. To support the request, the provider is asked to submit additional pertinent patient-specific information and scientific references. An eviCore board-certified medical oncologist reviews the revised regimen request and may approve it as clinically appropriate based on the supporting information submitted. If the request is not supportable based on all available information, the eviCore medical director will perform a telephonic peer review with the ordering physician to collaboratively discuss the details of the case and ultimately determine whether a guidelines-supported regimen or a customized regimen is most appropriate before issuing a final decision.

eviCore’s Claims Studio is an integrated system with over 85,000 proprietary and standard rules to accurately and consistently ensure that health plans and patients are responsible for only those healthcare claims that are authorized.

The success of the eviCore Medical Oncology solution to promote evidence-based cancer treatment and reduce drug costs was validated in a study published in the Journal of Oncology Practice (Oct 18, 2016), coauthored by Lee Newcomer, M.D., Senior Vice President of Oncology for UnitedHealthcare; Robert W.  Carlson, M.D., Chief Executive Officer of NCCN^®; and Richard Weininger, M.D., Senior Strategic Advisor and former Chief Medical Officer of eviCore healthcare. This controlled, prospective study demonstrated that the eviCore Medical Oncology solution reduced denials from 7% to 1% and increased compliance with NCCN Guidelines^® while reducing chemotherapy drug cost by 20% compared to the control group. The actual drug-cost savings was estimated to be $1.20 PMPM, without having to limit treatment options beyond the NCCN Guideline^® recommendations or patient’s choice of providers.

Our Medical Oncology solution optimizes the use of evidence-based clinical guidelines to deliver high-quality care to patients while avoiding the negative side effects and financial toxicity associated with unproven or less effective therapies.

Medical knowledge doubles every 73 days. Our Medical Oncology solution is a clinical decision support (CDS) tool that helps providers quickly identify the most appropriate evidence-based treatment options based on each patient’s unique clinical situation and the most up-to-date evidence.

Our Medical Oncology solution allows patients to have confidence that the tests and treatments they receive meet the standards established by the leading experts in their cancer type, drawn from the top cancer programs across the country. The solution offers the best chance for a positive outcome, and avoidance of the unnecessary costs and side effects associated with inappropriate health services (e.g., protracted therapy or avoidable emergency room visits and hospitalizations).

By integrating evidence-based medicine, outstanding clinical expertise and experience, and leading-edge technology, eviCore’s Medical Oncology solution improves the quality, safety, efficiency, and delivery of cancer care nationwide.