Life Sciences

Payers may forgo PA restrictions in more collaborative model

Medicare & Reimbursement Advisor Weekly, November 20, 2009

Even if the products you support are orals for cardiovascular conditions, the following may be helpful to give you insight into a plan’s new-age thinking about utilization management. A flurry of single-source biologics with attractive side effect profiles is expected to enter the cancer care market without competition in the next few years. Requiring prior authorizations (PA) on the coming wave of expensive oncology-specific biologics is an option “but not Aetna’s preferred option as it might preclude payers from engaging in relationships with community oncologists, academic centers, hospitals, and cancer centers,” says Aetna’s Ira Klein, MD, medical director of oncology condition analysis. In lieu of a PA, Klein says payers could try a single-specialty arrangement with an oncology provider, or build a private label insurance product in which the plan acts as a third-party administrator.

PAs would close the door to these arrangements and stall recent collaboration among oncology groups and payers.

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