Payer Approval for Frontline Options: Restrictive or Broad?

An expert medical practitioner discusses their experience receiving payer approval when choosing a frontline option for patients seeking management of their breast cancer.

Bruce Feinberg, DO: I always think of the NCCN [National Comprehensive Cancer Network] as the universe of options. I’m sure that the NCCN guidelines have to be more restrictive in universal options. I mean, in adjuvant, you know, adjuvant triple-negative breast cancer there’s 15 different regimens that are listed, and most have level 1 evidence because it’s 40 years of history. So I’m curious, typically, how many choices will there be that would be equivalent in a category?

We look at that first-line metastatic hormone-receptor positive, HER2-negative, how many different options will come up? Will all 3 CDK4/6 inhibitors come up, plus, potentially, 2 chemotherapy combination options? How restrictive, or how broad, is it? And, does it come up if you can reference it in a separate way? Or just, you pick what you pick and then you’re told yes or no?

Joyce A. O’Shaughnessy, MD: It’s very broad. It’s basically the NCCN choice of guidelines essentially with very few exceptions being off pathway, very few that are kind of borderline in terms of efficacy and quite expensive. So, no, it’s a broad choice. And their pathway list is long—it’s the NCCN Guidelines. And then if you need something different for a patient that doesn’t come up in the menu, there’s a separate box which you click and then you can search for the option that you need.

It’s quite straightforward. And like I said, it does; I think it’s fine. It allows a good projecting of what the cost will be, as we need to model what the total cost of care for populations is. But it allows us the flexibility which you must have when taking care of individual patients.

Bruce Feinberg, DO: All right. So Bill, I’m kind of surprised by your description of how broad the options are. It seems to me that even NCCN has come up with preferred regimens. So that may be a page of 15 that are level 1, but they’ve identified 2 or 3 that they think for different reasons are best among them. Do you have any kind of mechanism in your center that drills down to a smaller number, a smaller subset that would represent internal or house guidelines or pathways?

William J. Gradishar, MD: No. We don’t use pathways in our system. I think having seen what the reports are that are generated by the pathways, because McKesson Corporation and NCCN collaborate together. You know it’s fairly impressive. You can see on a very granular level what people are doing and what the costs are, et cetera.

We don’t have that ability, so I think that’s a problem, a little bit. You know, we still try to have physicians be physicians, not to be abstract artists out there doing whatever they want. I think most people conform to the standards that are dictated by things like NCCN or ASCO [American Society of Clinical Oncology] guidelines. But to be quite frank, we don’t have a way of actually looking at a granular level what each physician is doing. So we have to presume that they’re doing the right thing.

Bruce Feinberg, DO: And so, Steve, you do have a way but you’re doing it retrospectively, which is kind of problematic.

Steven Peskin, MD, MBA, FACP: Well, a lot of our information is limited to the tax identification number. So a large group like the one you were part of, or Bill or Joyce, we are getting individual physician level information with another technology company with which we work in cancer care, so that’s being, again, the idea there is to inform someone like a regional medical director, the type that Joyce mentioned, so the folks inside of that, the cancer organization or the medical oncology, radiation oncology, medical, plus surgical in some cases, is all under one roof. And so that’s been helpful.

We are also working on getting rendering-physician level through the NPI [National Provider Identifier] in our future state. But right now a lot of our efforts at describing costs are really related to the group level, not the individual physician level. So that is a limitation. And then, again, as I said, we do have this one organization we’re working with that’s helping us to better delineate, but not all, but the oncology groups that have adopted this particular company’s platform.

And then the last thing again is that we are in a pathway for all care, not only cancer care but pulmonary and endocrine, and everything else, urological, to be able to be at the rendering physician level, but we’re not there yet.

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