Effects of prospective review of medical oncology treatment plans (TPs) on quality of care, payer denial, and cost.

Abstract

e17565 Background: Retrospective review of chemotherapy TPs for compliance with expected care presents financial and quality risks to providers, patients and payers. Prospective assessment of TPs before oncology care is delivered may limit these risks. Methods: Through the eviti web-based decision support platform, oncologists/staff submit TPs for review. The eviti Evidence-Based Library incorporates all recognized guidelines (ASCO, NCI, ASTRO, NCCN and others), the supporting literature and NCI registered clinical trials. Evidence-based treatments are approved while unexpected variances are not reported to the payer until medical record review and peer to peer (P2P) discussion when records are insufficient. The eviti data base was queried for all off-study treatment plans submitted by medical oncology providers in a single state from January 2011 through October 2012. The nature of variation, results of P2P discussion and final recommendation to the payer were then determined. Net cost differences between the proposed and expected care were calculated using ASP+6% in November 2012. Results: Of a total of 202 TPs submitted on 116 individual patients, 89 TPs (44%) included 92 unexpected variations of care at initial submission, 11 of which (12%) presented safety issues documented in the peer reviewed literature and guidelines. The total net cost difference for one cycle of the proposed care and expected standard was $304,055. Of these 92 unexpected variations, only 29 (32%) of the variations could not be unjustified and referred for probable denial by the payer. After review of medical records, 21 (23%) were referred to the payer as medical justified variations (MJV), while after P2P 17 (18%) were considered MJV’s and 25 (27%) were modified to fit expected patterns of care. Additional analysis by drug classes and cost will be presented. Conclusions: In this TPs set, prospective review of treatment plans decreased the incidence of non-EBM care, the rate of potential denials, and the cost of care. Prospective TPs review can limit risk to all parties in cancer care.