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Elizabeth Danielson and Patricia J. Goldsmith

There is broad consensus that the United States' current health care system is deeply flawed with trends in spending that are unsustainable. The recent health care reform bill (Patient Protection and Affordable Care Act or PPACA) offers an opportunity for badly needed changes. Where substantial disagreement exists, of course, is where it's always found: in the details. We can agree on the need to reduce ineffective care and costs and give inefficient providers reasons to become more efficient. But how? Among the ideas gaining ground is a “restricted network” model that limits the physicians, hospitals, and other providers in the network to those viewed as less expensive, with no out-of-network coverage. Massachusetts recently enacted legislation that mandates insurers to offer at least 1 such network with a base premium at least 12% lower than that of the insurer's most comparable non-restricted network products. As noted in The Boston Globe (April 17, 2010), “Health insurers are starting to sell policies that largely bar consumers from receiving medical care at popular but expensive hospitals...—a once radical idea that is gaining traction as a way to control soaring health care costs.” Large managed care organizations are already developing or offering this type of product (The New York Times, July 17, 2010). It is widely anticipated that large academic cancer centers will also be excluded in this model. Although most hospitals and practices can undoubtedly find opportunities for efficiency, academic cancer centers face greater challenges, for reasons that include responsibility for training and commitment...
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Elizabeth Danielson, Jessica DeMartino and Jill A. Mullen

A previous NCCN Oncology Insights Report™ described the factors making cancer care a priority for managed care organizations (MCOs) and emerging trends in managing costs of cancer care. To better understand the concerns of MCOs and how they are addressing cancer costs and quality, NCCN interviewed senior physician executives from the 3 largest payors in the United States. The interviews provided insights into how these companies managed oncology care, with an emphasis on drugs and biologics. As a follow-up to the previous report, NCCN conducted additional interviews with medical executives from 10 MCOs between February and April 2010. The organizations represented in these interviews were Aetna, BlueCross BlueShield of Minnesota, BlueShield of Michigan, CareFirst BlueCross BlueShield, Empire BlueCross BlueShield, HealthNow, Humana, Independence BlueCross, Priority Health, and UnitedHealthcare. Although this group is diverse, it does not constitute a representative cross-section of MCOs across the United States. NCCN interviewed these executives about the priority of cancer care management for their organizations and the strategies being used to address cost and quality of cancer care. The information garnered from these interviews was qualitative in nature. A separate quantitative analysis of trends in oncology managed care has already been published, and throughout this report, data from the 2009–2010 Genentech Oncology Trend Report are referenced to supplement findings from the NCCN interviews.