CC&E: When the FDA issued its "Black Box" warning on ESAs, what was the reaction at UnitedHealthcare?
DR. NEWCOMER: Actually, we had been planning to institute our own policy regarding ESAs for 9 months prior to the FDA's impending "Black Box" warning.
Our policy was based on a pilot preauthorization program in our Oxford plan, which required adherence to ASCO and NCCN guidelines for ESA coverage. Based on that pilot, we put the guidelines into place, and within 6 months we saw a 30% decrease in ESA usage.
Due to the results of the Oxford program, we initiated a national policy requiring ESA claims to include a hematocrit level. If the hematocrit level exceeds 36%, the claim is denied, based on the ASCO guidelines.
CC&E: How many ESA claims does UnitedHealthcare handle per year?
DR. NEWCOMER: We process more than 500 million ESA claims annually. To accommodate such a large volume, we make certain compromises. For instance, we don't allow dosage adjustment above a hematocrit of 36% because claims systems can't read "half doses," patients don't have symptoms with a one or two point change in hematocrit, and the FDA recommends target levels of 30% to 33%.
CC&E: Do you have another example where your claims policy helped prevent unnecessary or inappropriate treatments?