Guidelines Might Solve Both Clinical, Economic Problems

June 1, 2006

The use of clinical practice guidelines such as those developed by the National Comprehensive Cancer Network (NCCN) is emerging as a key strategy for assuring cancer patients access to quality care; for empowering physicians professionally, politically, and financially; and for reducing health care costs. Panelists discussing "Oncology Practice Today" at the NCCN 11th Annual Conference repeatedly pointed to the usefulness of guidelines in quality evaluation, designing insurance coverage, and obtaining adequate reimbursement.

HOLLYWOOD, Florida —The use of clinical practice guidelines such as those developed by the National Comprehensive Cancer Network (NCCN) is emerging as a key strategy for assuring cancer patients access to quality care; for empowering physicians professionally, politically, and financially; and for reducing health care costs. Panelists discussing "Oncology Practice Today" at the NCCN 11th Annual Conference repeatedly pointed to the usefulness of guidelines in quality evaluation, designing insurance coverage, and obtaining adequate reimbursement.

The problem of assuring cancer patients access to high-quality care engaged all the panelists. Although this problem is sometimes presented in the consumer press as being a purely economic matter, patient advocate Mary Lou Smith, JD, MBA, who heads the Research Advocacy Network, Arlington Heights, Illinois, said that is not the case. "Not all patients [even with insurance] have access to quality care, defined as care according to accepted guidelines," she said.

Lee Newcomer, MD, of United HealthCare, Edina, Minnesota, illustrated the problem. "We insure over 100 million lives and spend about $3 billion on cancer care," Dr. Newcomer said. "A study of Herceptin [trastuzumab] claims showed that 12% of patients treated with Herceptin either did not have the genetic test [for HER2] or did not have the gene overexpressed. A potentially dangerous drug, associated with cardiovascular risk, was being given to many patients who were unable to benefit from it."

Blue Cross/Blue Shield's Allan Korn, MD, added another perspective from his group's experience insuring 94 million lives. Dr. Korn said that oncologists need to pay more attention to how they treat patients who are in the terminal stages of cancer. "When physicians fail to realize they are prolonging death rather than prolonging life, that is a failure of the system," Dr. Korn said.

Panel moderator Clifford Goodman, PhD, of The Lewin Group, Fairfax, Virginia, asked about the state of the art in assessing quality of cancer care. Jane C. Weeks, MD, of Dana-Farber Cancer Center, said that oncologists particularly need better ways to measure outpatient outcomes. "For most patients, adverse events come many years after treatment," she said.

Peter B. Bach, MD, of the Centers for Medicare and Medicaid Services (CMS), described the Medicare program's struggles with the quality issue. Dr. Bach said that current Medicare claims data are not sufficiently detailed to measure quality and that CMS is seeking methods for developing better data about disease characteristics and outcomes in individual patients.

"We need to pay for quality, but first we need to understand what it is and how to measure it," Dr. Bach said. He also pointed out that just the action of reporting in a standardized and proactive way has improved quality of care in pilot studies, a result known as the Hawthorne effect.

NCCN's Patricia J. Goldsmith said that NCCN sees the guidelines as a basis for working with payers to assess quality of care. Joseph S. Bailes, MD, interim executive vice president and CEO of the American Society of Clinical Oncology (ASCO), said that ASCO is looking at a similar approach. Dr. Bailes also pointed out that most oncology care is delivered at sites of five or fewer practitioners, where measuring quality of care is difficult using conventional methods but can be made easier using clinical practice guidelines.

Reducing Costs

Dr. Newcomer said that close adherence to clinical practice guidelines can be surprisingly profitable for small group practices. "Since adopting mandatory guidelines, last year we have lowered our fees, and our profits are the highest in 2 decades. This was from eliminating waste, which is very hard, and focusing on quality. We can afford the new technologies because we got rid of the waste," he said.

Money remains a significant barrier, however, Dr. Korn said. "The year 2006 is the year the average insurance cost for a family of four exceeds the income of a minimum wage worker," he said.

Several of the panelists expressed hope that widespread voluntary adherence to clinical practice guidelines might blunt Congress's current fondness for "pay-for-performance" (PFP) reimbursement schemes aimed at curbing waste. Dr. Bach warned that CMS expects a number of new PFP-based initiatives to be introduced into Congress this year.

Dr. Korn derided PFP for providing the wrong incentives at the wrong time. "PFP is like after the seal catches the rubber ball, you throw him the dead fish. What we want is not pay-for-performance but pay-for-excellence—the right care given the first time the right way, without waste. Please don't let Congress do this," he said.

Alice G. Gosfield, Esq, of Philadelphia, discussed the special legal advantages of guidelines, which offer a basis around which practices can integrate clinically for collective bargaining. "Physicians should stand up and take control," she said. "As a legal issue, clinical integration is a way doctors can come together and measure themselves against guidelines. It is important to know that physicians who are clinically integrated are allowed to bargain collectively with payers over fees, and guidelines can help."

Ms. Gosfield also noted that physicians who organize their practice around clinical practice guidelines greatly reduce their risk of malpractice suits. "Doctors who don't follow guidelines have a sixfold increased risk of being sued," she said. "Using guidelines to drive everything in clinical practice is the only clinically relevant way I can think of to organize health care in this country."

In a subsequent interview with ONI, Dr. Korn said, "I have great respect for the 19 NCCN institutions, and we would love to help give them teeth. BlueCross/BlueShield plans cover 94 million lives. Nineteen centers of excellence won't cut it. What we're looking at is using the NCCN as the core and developing concentric circles of excellence. So the patient gets good treatment but is not treated to death, to the point of spending only 2 days in hospice, which is what most oncologists are doing now."