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United experiments with new approach to encourage guideline concordant care

January 6, 2017

    Several years ago, UnitedHealthcare began piloting an online NCCN-based prior authorization system in an attempt to reduce denial rates and spending on chemotherapy drugs. A recent study reveals that the system was successful in meeting both of its aims.

    Keep reading to see how large the impact was and how UHC plans to further leverage this system.

    UnitedHealthcare's prior authorization system

    The UHC prior authorization system was jointly developed by UnitedHealthcare, NCCN, and eviCore Healthcare, a medical benefits management company. It was first piloted in Florida in May 2014 and launched nationwide in June 2015.

    The system exceeds standard prior authorization processes by providing clinical decision support, though it doesn't currently include treatment cost information. It's meant to replace UHC's post-service review process, which reviews claims to ensure compliance with the NCCN compendium prior to reimbursement.

    System reduced drug cost trend and denial rates

    The study compared chemotherapy drug cost trends between June 1, 2014 to June 1, 2015. They analyzed costs from the practices in Florida that were using the new prior authorization system against practices in other states that were using United’s traditional process of reviewing claims.

    The authors found a 19-percentage point difference between chemotherapy drug cost trends for the two groups: Florida’s trend decreased 9%, while the rest of the nation’s trend increased 10%. Furthermore, the denial rate for requests processed through the system during this period was just 1%.

    Users required to have clinical knowledge

    Because the system generates the authorized list of treatments based on patient clinical information, users need to be comfortable working with and understanding clinical data. Individuals traditionally responsible for conducting prior authorizations may lack the necessary knowledge so clinicians may be required to use the system to obtain authorization. This extra step in the care process will impact clinician workflow.

    Next steps focus on leveraging data

    In addition to ensuring NCCN guideline concordance, the system has the potential to improve care in other ways.

    For instance, the data captured in the system could be used to provide clinicians with real-world comparative data on treatments (toxicities, associated hospitalizations, etc.). It could also be leveraged in the future to negotiate drug prices with manufacturers and to identify high-value targets for phase III clinical trials.


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