Clinical, Claims Data Guide Care, Gold Carding: David Johnson, MD, MPH

Combining clinical and claims data can help oncology practices prioritize patients for supportive care and make gold carding a sustainable way to ease prior authorization burden, David Johnson, MD, MPH, explained in part 2 of an on-site interview at the Community Oncology Alliance Payer Exchange & Innovation Summit.

Johnson, who was a panelist during “The Evolution of Utilization Management: Data-Driven Decision-Making” session on September 14, is co-founder and chief physician executive at Atlas Oncology Partners and clinical associate professor of urology at UNC Health Care.

Technology can synthesize financial and clinical data into a holistic view of patients, Johnson told The American Journal of Managed Care^®. By pulling from disparate sources, including electronic medical records inside and outside the oncology practice as well as payer claims data, technology allows Atlas to risk stratify patients by medical or psychosocial risk, he explained. That stratification helps determine which patients to prioritize for engagement and which services they need to support better outcomes.

Johnson called utilization management an important tool for ensuring patients get the right treatment at the right time, noting that pathway recommendations and best practices will always play some role. Gold carding can reduce the administrative burden for both practices and payers, he said, but only under certain circumstances and with accountability on the care delivery side.

Qualification should rest on a provider's baseline prescribing performance, including adherence to national practice guidelines and avoidance of low-value therapies. Real-time data are then needed to confirm that performance holds after gold carding begins so deviations can be caught and corrected quickly and the benefits of a reduced prior authorization burden can be maintained.

These efforts are ultimately tied to quality, Johnson said, including whether supportive care reduces hospitalizations and increases time at home, which he called a “great metric” of care value. The goal at Atlas is not to restrict utilization through the “stick” approach payers often use, he added.

“We're really trying to incentivize appropriate care upstream and see if we can deliver on improved quality through decreased utilization of low-value services and increased utilization of high-value services that patients need,” Johnson concluded.