Impact of a regimen-level prior authorization tool on provider adherence to clinical guidelines’ and cost savings in a Medicare advantage population

• Published in: Journal of clinical oncology Vol. 39; no. 15_suppl; p. 1522
• Main Authors: Yeon, Heeseon, Brito, Rogelio Alberto, Kong, Wenjing, Cavers, William, Mcgovern-Siembab, Allendre, Claussen, Anne, Johnson, Kjel Andrew, Avalos-Reyes, Elisea
• Format: Journal Article
• Language: English
• Published: 20.05.2021
• ISSN: 0732-183X; 1527-7755
• DOI: 10.1200/JCO.2021.39.15_suppl.1522

Abstract only 1522 Background: In 2019, a large national health system developed a comprehensive approach to improve the quality and cost of cancer care; this solution included a Web-based clinical decision support prior authorization (PA) tool, Novologix (NLX), which approves at the regimen rather than drug level to reduce administrative burden and elevate the quality of care. Evidence-based guidelines in NLX are updated in real-time via a partnership with the National Comprehensive Cancer Network (NCCN). The purpose of this study is to evaluate the NCCN concordance of PAs submitted via NLX and total cost of care for Medicare Advantage (MA) patients with non-small cell lung cancer (NSCLC) who received NCCN concordant versus non-concordant therapies. Methods: Eligible patients included MA patients diagnosed with NSCLC; our initial analysis included only the NSCLC subset of patients. NCCN regimen concordance was identified from pharmacy and medical claims and defined as concordant if the entire prescribed treatment regimen matched an NCCN regimen; patients not receiving an NCCN recommended regimen were deemed to be non-concordant. Total cost of care for MA patients with NSCLC were calculated. Results: From April-December 2020, 279 PAs were submitted via NLX and 83% were automatically approved in real-time. PAs not automatically approved were deemed concordant after peer-to-peer consultations that led to NCCN concordance; no PA denials were made. In the first half of 2020, 2,690 MA patients with NSCLC were identified; 2,166 (81%) patients were defined as NCCN concordant. Beginning with and including the first treatment and for 30-days thereafter, total cost of care for concordant patients averaged $19,321 while non-concordant patients averaged $26,405, a statistically significant savings of $7,084 (p < 0.001). Conclusions: Preliminary findings with a MA NSCLC population suggest engaging oncology practices through an enhanced payer-provider collaboration and implementing an automated regimen-level precertification process with real-time NCCN updates can facilitate lower cost, and more efficient oncology care. Financial savings by encouraging providers to follow NCCN guidelines may lead to a 27% reduction in total cost of care with further proper adjustment on population bias; this may lead to similar findings in other cancer types. Future studies are needed to measure the long-term impact of this program on total cost of care for other care models and cancer types.