UnitedHealthcare Seeks to Improve Guideline Compliance

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Wall Street Journal

UnitedHealthcare, one of the largest insurers in the United States, has launched the Oncology Care Analysis database, which it designed with assistance from the National Comprehensive Cancer Network (NCCN). UnitedHealthcare plans to provide oncologists with assessments of their care for individuals with breast, colorectal, or lung cancer. The reports will highlight deviations from standard treatment guidelines, with the aim of getting physicians to avoid administering components of care that cost money but do not improve health. According to a article on the program, “some critics say that monitoring quality is not the appropriate role for an insurer, which has a financial interest in all this.”

But most insurers already have programs in place that reward primary care physicians for meeting certain performance measures, though few exist for oncology practice. Medicare instituted a voluntary Physician Quality Reporting Initiative 4 years ago, which includes some measures for oncology care, but a recent survey by the Medical Group Management Association found two-thirds of users are dissatisfied with its guidance.

The American Society of Clinical Oncology (ASCO) believes “providing high quality care to cancer patients is paramount,” and established the ASCO Quality Oncology Practice Initiative (QOPI) to improve practice. Registered practices submit data twice a year, which are compared to national guidelines, and participants receive a report 1 month later.

Wall Street Journal

Lee Newcomer, MD, the senior vice president for oncology at UnitedHealthcare, told the that the company found physicians did not comply with NCCN guidelines for colorectal cancer care in 31% of cases. Many patients were prescribed adjuvant bevacizumab (Avastin) instead of the recommended chemotherapy, a treatment Newcomer said is “unproven in that patient group.” Bevacizumab is also not approved as a front-line treatment after resection for colorectal cancer. UnitedHealthcare said its records also showed 24% of patients with non—small cell lung cancer were inappropriately treated with bevacizumab. In HER2-positive breast cancer, the main problem was patient adherence, with 38% failing to fill prescriptions for their aromatase inhibitors. UnitedHealthcare said 83% of its physicians complied with the standard treatment for this disease, which is trastuzumab (Herceptin).

One complication in rating oncologists for compliance with NCCN guidelines is that off-label use is common in treating cancer; the UnitedHealthcare study did not assess the reasons for physician noncompliance. This suggests that oncologists involved in programs to measure adherence to NCCN standards need to document reasons for deviating from these standards for a patient. This might include patient preference, incompatibility between the treatment’s adverse effects and the patient’s comorbidities, or the patient’s involvement in a clinical trial, for example. This will help provide a better grasp of what work needs to be done to improve adherence to meet the established best standards of care.

Wall Street Journal

Newcomer said the reports will not be used to rank physicians, though he did not rule out making the information more widely available if quality of care does not improve. Nor does UnitedHealthcare intend to tell physicians how to practice medicine. “I think we can inform decisions, not make them,” Newcomer told the .

The UnitedHealthcare program operates similarly, collecting clinical information from oncologists, compiling it with patient claims data, and comparing it with NCCN guidelines. Reports are then mailed to individual oncology providers. UnitedHealthcare said it was especially concerned with the improper use of expensive biopharmaceuticals.