When a handful of oncologists from competing institutions gathered their expertise and egos together in a joint effort to define appropriate care of patients with cancer, it wasn’t entirely clear the endeavor would work. Shared concerns about HMOs had brought them together in the mid 1990s, but they also vied for the same grants, philanthropic gifts, and patients.
Under the deft leadership of the late Dr. Roger J. Winn, the National Comprehensive Cancer Network (NCCN) has parlayed that first guideline, published in 1995, into the most widely used clinical practice guidelines in oncology. By the NCCN’s own account, the guidelines cover 97% of all patients with cancer. Last year alone, nearly 3.3 million PDF copies were downloaded, with select editions now available in 10 languages including Mandarin and Turkish.
The NCCN, which has seen its original budget increase from $2 million to a little more than $30 million, also successfully flexed its political muscle in recent months over the issue of risk evaluation and mitigation strategies (or REMs), and expanded its global reach through conferences in Beijing, Brazil, and Abu Dhabi.
Membership in the not-for-profit alliance was capped 2 years ago at 21 cancer centers in the United States. These member institutions fund the guidelines through dues and millions of dollars worth of free time, said Dr. David S. Ettinger, the Alex Grass professor of oncology at Johns Hopkins University, Baltimore, and chair of the NCCN’s non–small cell lung cancer and occult primary clinical practice panels.
“Fifteen years later, although there may still be some differences, the guidelines are as specific as you can get,” he said.
They also hold tremendous sway with public and private insurers, raising concerns over how they are being used and whether strict adherence can lead to “cookbook” medicine.
Insurers Base Coverage on Guidelines
The NCCN tracks and monitors guideline compliance for breast, colorectal, non-Hodgkin’s lymphoma, non–small cell lung cancer and, most recently, ovarian cancer, with compliance at about 90%-92% for recommendations with level 1 evidence and 85% overall, said NCCN chief executive officer William T. McGivney, Ph.D. For the remaining 15%, patient characteristics, patient preference, and physician disagreement with the guidelines will direct care. The transparency of the guidelines allows physicians to review the references, the category of evidence, and level of consensus, and decide on their own to use them or not, he said. Still, Dr. Ettinger acknowledges that treatment “decisions are made not wanting to fight insurance companies.”
The NCCN noticed early on that its guidelines were being used as the basis for setting coverage policy, prompting the creation in 2004 of the first NCCN Drugs and Biologics Compendium, Dr. McGivney said. The compendium is now used by such key stakeholders as the Centers for Medicare and Medicaid Services and UnitedHealthcare Inc., one of the nation’s largest private insurers.
“On the private side, you see payers basically saying “If it’s in the NCCN Compendium, it’s covered,’ which is critically important for clinicians and patients,” he said. “We have tremendous influence and collaborative influence I think, with payers.”
If a physician uses a drug covered by the compendium to treat any of the 20,000 patients UnitedHealthcare (UHC) has on active chemotherapy in any given year, the drug is automatically covered, said Dr. Lee N. Newcomer, senior vice president, oncology, for the Minnesota-based insurer. Cases involving drugs not covered by the compendium are reviewed by a medical director who looks at state laws and regulations and the employer’s specific requirements. If an employer requires that any chemotherapy recommended by a physician is covered, then the drug would be covered by UHC, even if it’s not in the compendium, he said.
Prior to UHC’s adopting the compendium, 15% of treatments given by its oncologists didn’t match NCCN recommendations. “I would argue that this was both waste and exposing patients to toxicity and drugs that wouldn’t help them,” said Dr. Newcomer, adding that noncompliance is now less than 1%.
Oncologists Rated on Quality of Care
Earlier this year, UHC unveiled the Oncology Care Analysis program that uses clinical and claims data from about 2,600 oncologists and 14,000 patients from across the country with breast, colon and lung cancer to gauge quality of care based on adherence to NCCN guidelines. Oncologists receive a report showing their individual results along with aggregate national results.
Dr. Newcomer dismisses concerns that the program could pressure oncologists into making treatment decisions based on their standing with UHC rather than the best choice for patients who don’t fit the guidelines because such patients are excluded from the analysis. Moreover, there are no financial incentives or penalties associated with the program. “UHC has always emphasized that the information is for quality improvement,” he said. “We let physicians decide how to act on the information.”