During this segment, the panelists share insights about clinical practice guidelines such as those released by the National Comprehensive Cancer Network (NCCN) and Centers for Medicare & Medicaid Services (CMS) and discuss their impact on managed care.
The panelists explain that as organizations such as the NCCN and CMS continue to enforce stricter requirements with more paper work than previously, when payers try to adjudicate the quality of the evidence and look to a panel of experts to help them negotiate expenses, it impacts managed care.
Michael Kolodziej, MD, suggests that currently the payers are the gatekeepers when managing this information. However, a shift to providers becoming the gatekeepers is under way.
Jeffrey Weber, MD, PhD, is concerned that this shift will burden providers. However, Dr Kolodziej and Daniel J. George, MD, disagree, and explain that the forms that are required to be filled out are simple and brief.
Dr George explains that the burden occurs when coverage for expensive cancer immunotherapy agents is denied. At this point, a peer-to-peer process is requested, in which a healthcare professional discusses the case with another healthcare professional. The peer-to-peer process includes additional reviews and takes a considerable amount of time.