Improving Medical Oncology Quality Through Peer-to-Peer Consultation.

Purpose: This study describes how the use of peer-to-peer (P2P) physician consultation improves medical oncology care quality by preventing non-evidence-based and potentially morbid chemotherapy treatments. New Century Health (NCH) has adapted a physician audit and feedback model to strengthen adherence to clinical guidelines. In the NCH oncology program, P2P consultation complements clinical pathways and an online prior authorization platform. Payers are adopting the use of clinical pathways as a management strategy for managing costs and improving quality. Managing medical oncology is a complex process, because evidence evolves rapidly, and almost one third of chemotherapy is prescribed off label. The use of prior authorization, combined with standardized protocols for patients with specific cancer diagnoses, is one way for payers to reduce unnecessary treatment variation. [Table: see text] Methods: NCH completed a retrospective analysis of the chemotherapy treatment requests (CTRs) submitted by payers' oncologists for prior authorization between January and December 2012. The objectives of the clinical impact analysis were to measure the CTR disposition rate, identify the CTR intervention rate resulting from P2P consultation, and identify the types of drug triggering the interventions.

Results: Analysis of the 13,078 CTRs associated with the 1,116 unique Medicare and commercial patients of a national health plan determined that CTRs voluntarily withdrawn or recommended adverse determination (RAD; ie, NCH recommendation to member's health plan to not authorize treatment as requested; after review of health plan policy and compendia, NCH was not able to resolve provider's request through P2P consultation and could not recommend approval of treatment plan as requested, therefore recommending denial of request) by the submitting physician as a result of a P2P consultation with an NCH board-certified oncologist comprised 11.6% of all CTRs. Further analysis identified the types of medication associated with the 1,521 CTRs withdrawn/RAD as a consequence of P2P consultation. Interventions on chemotherapeutic medications and supportive care were evenly distributed at 51.2% and 48.8%, respectively. Interventions on medications that had received US Food and Drug Administration approval within the last 2 years (initial approval or for new indications) represented 12.1%. [Table: see text] Conclusion: Using P2P consultation to complement a pathway-driven prior authorization process improves medical oncology quality. In addition, P2P consultation can be an effective collaborative physician engagement strategy by supporting oncologists with critical clinical information and mitigating concerns about pathway implementation and about payer involvement in drug use management.