Staying True to a Mission: NCCN Then and Now

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Robert W. Carlson
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The original concepts that formed the foundation of NCCN were established in 1993 by leaders from 5 institutions—City of Hope National Medical Center, Fox Chase Cancer Center, Fred Hutchinson Cancer Research Center, MD Anderson Cancer Center, and Memorial Sloan-Kettering Cancer Center. Leaders from these 5 institutions were concerned that the managed care organizations of the 1990s posed a substantial risk to the survival of the academic cancer center because of inadequate rates of reimbursement. The managed care organizations were concerned that the academic cancer centers overtreated many patients. The original NCCN business plan was finalized in September 1993, responded to both the academic cancer center and managed care organization perspectives, and identified 5 goals and objectives for the organization.

Two of these goals and objectives related to clinical end points:

“To enhance and control the quality of cancer treatment through the combined efforts of the centers to develop standard treatment protocols, and to place patients in the most appropriate settings, diagnosing and treating the initial stages of cancer properly so as to achieve efficient use of resources and improve outcomes.”

These goals and objectives assured the managed care organizations and other third-party payers that the NCCN Member Institutions would commit to standardized treatment protocols to optimize patient outcomes in a cost-effective manner. The result was the development of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines), which have evolved to cover more than 97% of all patients with cancer in the United States. The NCCN Guidelines have also evolved in complexity and utility. For example, the original NCCN Guidelines for Breast Cancer, published in 1996, were 29 pages long and were developed by a panel of 7 physicians (4 medical oncologists, 2 radiation oncologists, and 1 surgical oncologist). Version 3.2013 of the NCCN Guidelines for Breast Cancer is 176 pages long and was developed by a panel of 28 members (16 medical oncologists, 3 surgical oncologists, 3 radiation oncologists, 2 pathologists, 1 nuclear medicine physician, and 1 patient advocate), and additional NCCN Guidelines are now available for Breast Cancer Risk Reduction, Breast Cancer Screening and Diagnosis, and Familial and Genetic High-Risk Assessment: Breast and Ovarian. Similar evolution has occurred in multiple other NCCN Guidelines, and now more than 1000 physicians currently participate as panel members in the NCCN Guideline development process. The NCCN Guidelines now also include an assessment of the quality of the scientific evidence and more than 800 biomarkers, and are being used as the basis for the development of treatment pathways.

The other 3 goals and objectives of the original 1993 NCCN business plan focused on coverage and reimbursement issues—developing national managed care contracts, partial or full-risk payment arrangements, and products and services for adoption by self-insured employers or managed health care plans. These 3 areas of focus continue to be central to NCCN and its member institutions. The Affordable Care Act, oncology medical homes, and accountable care organizations are all ongoing efforts to develop national health care programs that impact all cancer centers in the United States. The ability of cancer centers, including the NCCN Member Institutions, to respond to these changing market forces is central to the survival of the academic cancer center in the United States.

NCCN continues to focus on quality of care that extends well beyond the NCCN Guidelines and includes efficiency of care, patient satisfaction, availability of high-quality clinical trials, and education for patients and for health care professionals throughout their careers. NCCN recently completed a major collaboration with the National Business Group on Health to develop an extensive and detailed toolkit to assist employers in developing and evaluating coverage across the spectrum of cancer prevention, treatment, and survivorship.

In looking at the 1993 NCCN business plan, I am struck by how the core themes of the organization have persevered. The NCCN Guidelines remain the core product of the organization and have come to define the standard treatment of cancer in the United States and, increasingly, in the world. NCCN continues to focus on ensuring that patients are treated in the most appropriate settings to optimize outcomes and provide efficient clinical care. NCCN is solidly in the vanguard of doing it right the first time to optimize patient outcomes and efficiently use limited resources. Use of the NCCN Guidelines assures that health care systems provide truly state-of-the-art care by following continuously updated recommendations in the rapidly changing landscape of modern oncology treatments.

The focus on coverage and contracting issues has evolved in response to the ever-changing reimbursement environment and market forces. However, the need for the health care delivery system to develop products and services that will be adopted by payers, optimize patient outcomes, and adequately support the health care system, including academic cancer centers, remains as crucial today as it was in 1993. The ongoing transformation of the US health care system under the Affordable Care Act makes the present time one of both enhanced jeopardy and enhanced opportunity for cancer care. The practical difficulties in the implementation of the Affordable Care Act demonstrate that the goal of ensuring patient access to care continues to be challenging, and that accessing and ensuring the financial survival of our health care systems is often as challenging as providing quality care.

The early leaders of NCCN established an effective course and meaningful mission and vision for the organization that carries forward 20 years later. Cancer care and the US health care system will undoubtedly continue to evolve, and those who provide cancer care, both in community centers and in academic cancer centers, must respond to that evolution if optimal and efficient care is to be provided to patients. Given the challenges and changes of the past 20 years, just imagine where we will be in 2034!

Robert W. Carlson, MD, is the CEO at NCCN, and has an esteemed history of leadership positions within the organization including member of the NCCN Board of Directors, chair of the Breast Cancer Guidelines Panel, member and founding chair of the Breast Cancer Risk Reduction Guidelines Panel, and chair of the Survivorship Guidelines Panel.

Before his appointment as CEO, Dr. Carlson served as Professor of Medicine in the Division of Oncology and Stanford Medical Informatics at Stanford University Medical Center.

He is a graduate of Stanford University Medical School, and completed his internship and junior residency in internal medicine at Barnes Hospital Group in St. Louis, Missouri, before returning to Stanford University to complete his senior residency.

Dr. Carlson is a member of several medical societies, including American College of Physicians, American Association for Cancer Research (AACR), and ASCO.

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of NCCN.

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