Appropriate use of clinical pathology laboratory tests to detect and treat cancer will be a scorecard factor

One primary goal of pay-for-performance programs is to reduce or eliminate the variability of care that physicians provide to their patients. Getting physicians to follow the recommended care protocols 100% of the time with 100% of their patients would contribute to improved outcomes, while reducing overall healthcare costs.

Pathologists and clinical laboratory professionals are well positioned to see this variability in care, since they regularly handle the laboratory test requests from client physicians. Over time, they can recognize the good and bad practice patterns of individual doctors, since it is reflected in both the lab test orders and the laboratory test results for that doctor’s patients.

Not everyone thinks that an insurance company is the most appropriate group to monitor quality of care.

Now comes news that UnitedHealthcare, one of the largest insurers in the nation, launched a two-pronged action to help ensure that cancer patients get the most appropriate—and the most cost-effective—care. The program is called Oncology Care Analysis (OCA). It includes a unique database to gauge quality of care based on guidelines from the National Comprehensive Cancer Network (NCCN). It also provides direct feedback for oncologists regarding their compliance with the guidelines.

In early February UnitedHealth announced implementation of its new cancer registry that combines clinical and claims data. It allows UnitedHealthcare to compare the care provided by an oncologist to a patient to see if it complies with the NCCN Clinical Practice Guidelines in Oncology™ and the NCCN Drugs & Biologics Compendium™. The Compendium, which is based on the Guidelines, contains information designed to support decision-making about appropriate use of drugs and biologics for cancer patients.

In November 2009, before announcing the new cancer registry, UnitedHealthcare shared OCA program patient data with about 1,500 participating oncologists to help them “better understand the strengths of their patient care along with areas for improvement,” according to the company’s press release.

In this program, the oncologists received aggregate national program results in addition to their individual results. Each oncologist also got relevant guideline data for each eligible patient under their care. Next, UnitedHealthcare shared aggregate national results with an additional 12,000 oncologists in its network as a way to introduce the patient care tool and the cancer registry program.

Confirming that one goal of the new program was to reduce variability in care as provided by different oncologists, Lee N. Newcomer, M.D., UnitedHealthcare’s Senior Vice President, Oncology stated: “Treatment of cancer varies widely among doctors and hospitals in the United States. The Oncology Care Analysis program’s goal is to help improve quality and coordination of cancer patient care by providing oncologists with information and feedback relevant to the care they are providing to their patients.

Not everyone thinks that an insurance company is the most appropriate group to monitor quality of care. Eric Winer, M.D., Chief Scientific Adviser for the Susan G. Komen Foundation, told the Wall Street Journal, “This is one area I’d rather have doctors police themselves than have an insurance company do it.”

Blogs on several medical news websites questioned the algorithms used by the OCA program to measure physician compliance with the guidelines. Many physicians are concerned that a too-rigid measurement system may steer physicians away from treatments that might be appropriate for individual patients. Another concern is that UnitedHealthcare’s motives are more about cost than quality.

Still, even the American Society of Clinical Oncology, which has its own quality-assessment program, thinks that insurers have a role to play. It has enlisted the help of insurers to recruit physicians for the program, including Blue Cross/Blue Shield of Michigan. And insurers have ready access to claims data, which can offer insights that can’t be found in the medical record kept by individual oncologists.

For example, the UnitedHealthcare database can give the oncologists information about which treatments were provided by other physicians to their cancer patients. As well, UnitedHealth can give the oncologist regular updates on how often patients filled their prescriptions. This gives oncologists access to a more complete set of data regarding all the treatment a patient has received for other physician that are part of his/her care team.

The NCCN collaborated with UnitedHealth on the OCA program, and William T. McGivney, Ph.D., NCCN Chief Executive Officer, voiced his support, saying “We applaud UnitedHealthcare’s leadership in working with physicians to improve outcomes for cancer patients.”

A particular area of concern for UnitedHealthcare is whether oncologists are appropriately using expensive biopharmaceuticals. For example, the NCCN guideline for colon-cancer patients advises that patients get chemotherapy after surgery. UnitedHealthcare determined that, in 31% of colon cancer cases, the care did not comply with the rule. Instead, many patients were prescribed Avastin, a Roche biologic that is not recommended for initial treatment after surgery. Rather, Avastin is approved for treatment of recurrent or metastatic colon cancer.

UnitedHealthcare also found that about 24% of patients with non-small-cell lung cancer received Avastin, even though this disease didn’t meet the criteria to get that drug.

UnitedHealthcare’s implementation of a “best practices” program designed to reduce variability of care in oncology shows how timely access to integrated patient data and recommended care protocols will be the next step insurers use to improve health outcomes in a way that also helps control the cost of care.

These types of programs will be positive for clinical laboratories and pathology groups. It can be expected that, as physicians get regular information on how their patient outcomes compare with peers, they will be motivated to improve how they utilize laboratory tests for diagnosis, deciding treatment options, and monitoring the patient’s progress.

Further, a program like UnitedHealthcare’s Oncology Care Analysis has the potential to raise the profile of the pathologists as an essential consultant on the patient’s care team. That’s because pathologists are the experts in how to best use the increasingly sophisticated genetic and molecular tests for cancer that are the first steps on the road to personalized medicine.  —K. Branz

Related Information:

Insurer Plays Judge on Cancer Care

UnitedHealthcare Sends Doctors Individualized Reports

UnitedHealthcare Creates Adult National Cancer Care Registry with Data and Analysis to Support Oncologists in the Fight against Cancer

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