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

May 11, 2017

The American Society of Clinical Oncology (ASCO) released a statement on April 18, 2017 urging payers not to use utilization management (UM) approaches that would limit cancer patients’ access to high-quality high-value care. The organization 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.”[1]

ASCO quoted its president, Daniel F. Hayes, MD, FASCO, FACP, as saying: “Utilization management strategies, when implemented without appropriate patient safeguards, can impede patient access to high-value, clinically appropriate care. Payer policies must reflect the current requirements of contemporary cancer care and be evidence-based on what constitutes high-quality care.”[2]

Time is of the Essence with Cancer

Because time is of the essence in most cancer cases, patients cannot wait to receive certain drugs and could suffer irreparable damage if denied the use of such drugs by their health plan. ASCO states that “high-quality clinical pathways are payers’ best first option to ensure appropriate utilization of anti-cancer drugs and the delivery of high-quality high care yielding optimal benefits and outcomes.”[3]

We have made advances in cancer and much of this is due to high-quality drugs administered in a timely fashion to patients. ASCO, in its 3rd annual State of Cancer Care report published in April 2016, reports that the FDA “added 15 new drugs and biologic therapies to its list of more than 180 approved anticancer agents and expanded use for 12 previously approved treatments in 2016.[4]

Managing an Unsustainable Financial Burden

The cost of cancer drugs places a hardship on both patients and health plans. Patients bear higher portions due to high deductible plans, and payers straddle a fine line in providing the best care for their members while managing huge cancer care costs. ASCO says, “High unit cost and inconsistent reimbursement policies across payers hinder patients’ access to immunotherapies. Emerging data suggest that using drugs in combination and at higher doses increases efficacy, making the prospect of an unsustainable financial burden – for both patients and the system – more likely.[5]

ASCO’s Concerns and Recommendations

ASCO asserts that the following are current UM policies used by both public and private insurers “to control the use of anti-cancer drug therapies,”[6] including:

  • Prior authorization requirements
  • Restrictive formularies
  • Step therapy (fail-first requirements)
  • Specialty specific tiers

 

The ASCO statement also establishes a framework for evaluating the impact of coverage or utilization management strategies on the care of patients with cancer:[7]

  • 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.

 

ASCO’s full statement can be accessed as a PDF.

 

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[1] American Society of Clinical Oncology,”ASCO Opposes Payer Utilization Management Approaches that Curb Access to High-Quality, High-Value Cancer Care,” ASCO in Action, Apr. 18, 2017, https://www.asco.org/advocacy-policy/asco-in-action/asco-opposes-payer-utilization-management-approaches-curb-access-high

[2] Ibid.

[3] Ibid.

[4] M. Kelsey Kirkwood, MPH, American Society of Clinical Oncology, “The State of Cancer Care in America, 2016: A Report by the American Society of Clinical Oncology,” Apr. 2016, The Journal of Oncology, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015451/

[5] ASCO, “ASCO Opposes Payer Utilization Management,” https://www.asco.org/advocacy-policy/asco-in-action/asco-opposes-payer-utilization-management-approaches-curb-access-high

[6] Ibid.

[7] Ibid.