Oncology services for members of a national managed care company.

Abstract

Oncology services in a managed care organization may be defined by the structure of the provider network, coverage policies, and specific health plan programs for oncology services. The policies and programs of Aetna U.S. Healthcare were reviewed to illustrate the approach of a large, national health benefits company in the provision of oncology services to its members. Standard oncology services are provided by a network of independent participating providers, paid fee-for-service. There are no capitated arrangements for oncology services. The process is driven by the participating providers. For patients requiring bone marrow transplant or therapy available in few medical centers, precertification and case management are provided by the health plan, through the National Medical Excellence Unit. Criteria are used to select facilities for these services and global case rates are negotiated. In the health maintenance organization, educational material is distributed by the health plan to physicians and members to encourage the use of cancer screening services. In addition, reimbursement to primary care physicians can be enhanced by the screening rate for their members. The overall policy of Aetna U.S. Healthcare is to cover Phase II and III clinical trials. Coverage for Phase I trials or use of non-Food and Drug Administration approved drugs is based on reported safety and efficacy and participation in an academic program. Through arrangements with participating providers, dedicated support for transplant and rare cases, programs encouraging the use of cancer screening, and member-focused policies on coverage issues, managed care companies can provide complete oncology services to its membership.