Top Two Wish List Items Oncologists Want from Payers

Two oncology practices have wish list items for payers. Both requests are about improving patient care.

Request #1: Standard protocols across payers

Barry Russo, CEO at Fort Worth, Texas-based Center for Blood and Cancer Disorders, says it is “ridiculous” that his practice needs to hire seven full-time people to secure payment for treatments that have been FDA approved and follow treatment guidelines.

This number of staff members is required because each payer has its own criteria for coverage of treatments, says Monica Rampone, manager of precertification and referrals. In a practical sense, that requires Rampone, or one of her team members, to log into and enter information into each payer’s online portal to request coverage of the treatment. Even more frustrating, she says, is when payers require the practice to fax this information.

Standard protocols across payers would mean the practice wouldn’t need to hire so many people to do this work, and it would expedite the treatment process, says Rampone.

She describes it as “disappointing and frustrating” to have to tell patients their treatment won’t be covered by the payer. Or that the treatment may be delayed because the practice needs to resubmit the coverage request, and then wait an additional two days for a decision-that’s on top of the initial two days the practice had to wait after submitting the request.

Also frustrating is that payers’ formularies may take three to six months to catch up with FDA approval of new drugs, says Rampone. Case in point: Keytruda (pembrolizumab), an immunotherapy treatment, and Avastin (bevacizumab), an infusion, both of which treat a variety of cancers.

“We need to start this for our patient right away. It can be the difference between them having even just a little better quality of life. That should be our goal,” she says.

Rampone understands that payers can’t approve every request-and understands that the cost of immunotherapy drugs, in particular, is high. Still, she’d like to see more standardization across payers in terms of their coverage requirements and leeway in coverage for treatments that her practice’s oncologists have researched and believe would help their patients.

Request #2: Medication without requiring a colonoscopy

Ann McGreal, RN, oncology nurse clinician at Park Ridge, Illinois-based Advocate Lutheran General Hospital, wants payers to have more realistic requirements when her practice’s patients need coverage for treatments such as Remicade (infliximab). This medication can be used to treat immune-mediated colitis, which often occurs with patients receiving immunotherapy treatment.

The problem? CMS and some private payers require a biopsy to prove the patient has this diagnosis.

That requires that practice to make a patient who’s experiencing “life-threatening diarrhea,” to experience a colonoscopy, says McGreal. “This is a patient who’s one step away from the hospital. We have a patient who has probably lost weight and is probably malnourished because we haven’t been able to control the problem.”

She says payers previously would approve the treatment without requiring the colonoscopy, once it was established that the patient had non-responding, immune-mediated colitis. That meant the patient didn’t respond to standard, normal treatment, which is typically anti-diarrheal medications and/or high-dose steroids.