In January, Bend, Ore.-based St. Charles Health System launched a pilot program alongside the insurer PacificSource to streamline automatic coverage approval for patients needing cancer treatment.
St. Charles' President and CEO, Steve Gordon, MD, joined the Becker's Healthcare podcast to discuss the new initiative, an episode that will air later this month. Tune in to hear about future plans for the pilot program and Dr. Gordon's advice for health systems looking to replicate St. Charles' success.
Question: St. Charles has a new pilot program in your cancer center alongside the insurer PacificSource that you say is making prior authorization "a thing of the past." Can you share more about the program and how it came about?
Steve Gordon: Imagine you are a cancer patient and you've just been given a diagnosis by your oncologist, which is terrifying news that comes with a treatment plan or recommendation that may include chemotherapy, radiation or a combination. As soon as we receive authorization from your insurance plan, we can begin treatment, but how long is that going to take? We're never quite sure — it can be a couple of days, but it may also be a couple of weeks. For us, the immediate question is on what basis is the care plan being reviewed by the payer and a decision made whether or not to approve the plan? It turns out that many plans utilize a set of guidelines that have been in development by the National Comprehensive Cancer Network (NCCN) for more than 20 years, which use those guidelines to adjudicate whether the care plan recommended by the oncologist is concordant or discordant with national guidelines. Our observation was that the same NCCN guidelines have been the basis for our own quality cancer program for 20 years, and we are routinely reviewed and re-accredited by the NCCN against their standards of care. We routinely adhere to NCCN guidelines 90-95% of the time, and the exceptions are the rare or complex cases for which definitive data doesn't yet exist.
So we said, this doesn't make a lot of sense because we know that the care plan is eventually going to be approved. Nevertheless, we were waiting days, sometimes weeks for that approval to come through. The program that we have been piloting now since the beginning of the year takes that pre-approval process and turns it on its head. Because of our track record in already adhering to NCCN guidelines, our cancer patients will be automatically or near instantly approved for care, and we will concurrently review the rare outlier cases with the plan and their experts to agree that our decision is consistent with their experts. Instead of all patients having to wait for an approval that we knew was eventually going to come, now that approval is coming instantly on the same day.
Q: Did you approach PacificSource with the proof of meeting these national guidelines and they then agreed to this arrangement?
SG: That's exactly how it came about. One of the important drivers was the recognition that not only were patients needlessly waiting for an approval that the plan was going to issue eventually, but the administrative effort from both parties to submit and work through approval was itself contributing to administrative waste and burnout. In my view, it's a rarer, much desired example where we can simultaneously eliminate administrative burden and drive an improved clinical outcome. Long approval wait times were not only anxiety-provoking for patients, but probably were tied to adverse outcomes in certain instances where time is so critical for starting necessary and recommended treatment.
Q: What clinical outcomes are you now seeing with your patients?
SG: We've been very cautious on how to measure and report on data like this, but in the first three months of our experience, we are finding that more than 80% of patients in the pilot are having their treatment plans approved the same day, and therefore can start the following day. That compares to approximately 50% of all our other patients. It is important to recognize that we do have a number of patients whose plans don't require prior authorization, such as traditional Medicare. But overall, we've already seen a significant reduction in the number of patients who have to wait more than a day for their insurance approval.