1. Navigating The Oncology Care Maze:
Evidence Based Medicine As A Pathway For
Payers, Providers & Patients
The Center For Business Intelligence
3rd Annual Effective Oncology Benefit Management Conference
October 6, 2008
Dr. Mickey Goldsmith
Chief Medical Officer, New Century Infusion Solutions

2. Why I’m Facilitating This Workshop
I have a broad perspective on oncology care:
• Practicing community oncologist 25+ years
• Managed care executive & medical group CEO
– City of Hope Oncology Network
• Single specialty IPA with 800,000 lives
• Speaker on oncology managed care issues
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3. Why I’m Facilitating This Workshop
– Currently Medical Director of New Century Infusion
Solutions (NCIS)
– NCIS is the first Integrated Single Specialty Provider
(ISSP) in oncology
– A new type of health care payer
» Takes risk
» Capitated (professional, drugs & radiation therapy)
» “Payer for the payers”
– Share NCIS experience
• Policies developed from EBM can cost effectively deliver
oncology care
• Specific takeaway ideas other payers can use
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4. Workshop Agenda
• The Oncology Landscape
– Current perspectives
– A new perspective
• Evidence Based Medicine
– What it is, & what it is not
• EBM in Community Oncology Care
– 5 specific examples
• Case Study Exercise
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5. The Oncology Care Landscape
Current Perspective
Payers
• Challenges
– Supporting Cost-effective Cancer Care
– Controlling Rapidly Escalating Rx Costs
– Managing Off-label Rx Use
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6. The Oncology Care Landscape
Current Perspective
Providers
• Challenges
– Incorporating Evolving Standards of Care Into
Practice
– Receiving Adequate Reimbursement
– Utilizing New Agents and Therapies
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7. The Oncology Care Landscape
Current Perspective
Patients
• Challenges
– Working with payers and providers to access
appropriate care in a timely manner
– Receiving high quality cancer care
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8. The Oncology Care Landscape
Current Perspective
Patient Need for
Quality Care
New
Research
Provider Off-Label
Fees Rx
New
Agents
Rx Costs
Delivery of Cost Effective
Oncology Care
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9. Changing the Oncology Care
Landscape
There’s a need for a new type of oncology care system
to handle the financial and clinical challenges of care
from all perspectives:
•Financial challenges
– Some heath care plans can’t manage risk or are unwilling to
bear all of the risk
– ASP +6 reimbursement poses serious practice sustainability
challenges for many providers
– Acceptance by provider of drug replacement & “brown bag”
issues
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10. Changing the Oncology Care
Landscape
There’s a need for a new type of oncology care system
to handle the financial and clinical challenges of care
from all perspectives (continued):
•Clinical
– Many community oncologists have difficulty keeping up on
alternative treatments and advances in the standard of care
published in the literature
– Payers need to know which treatments are appropriate
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11. The New Oncology Care Landscape
Leveraging the power of EBM can change the landscape to:
Payer
Prior
Information
Authorization
Technology
Provider Provider
New
Network Professional
Agents
Fees
Patient
Provider Site of Rx Off-Label Rx Preferred
Fees Administration Drug List
Delivery of Cost Effective Oncology Care
Patient-Centered EBM Care & Guaranteed Payer Savings
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12. The New Oncology Care Landscape
• New Century Infusion Solutions
– Overcomes key payer challenges
• Cost escalation
• Over & under utilization
– Solves key provider challenges
• Responsive prior authorization policies and processes
• Appropriate and timely reimbursement
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13. The New Oncology Care Landscape
• New Century Infusion Solutions resolves the financial
and clinical challenges of cancer care
– Financial
• Assumes the risk
• Acts as the “payer for the payer”
• Facilitates delivery of appropriate care by eliminating
reimbursement misalignment between payers, providers and
pharmacy
– Clinical
• Uses EBM as a patient-centric pathway to deliver full spectrum
oncology care
• EBM optimizes curative, adjuvant and palliative therapies
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14. Evidence Based Medicine
The fact that an opinion has been
widely held is no evidence
whatever that it is not utterly
absurd…
-Bertrand Russell, philosopher, historian, logician
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15. Evidence Based Medicine
Evidence-based medicine is the
conscientious, explicit and judicious
use of current best evidence in making
decisions about the care of individual
patients.
- The Cochrane Collaboration
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16. Evidence Based Medicine
(EBM)
What it is What it is not
• Based on Research • Uniformly practiced by
• Dependent on quality of clinicians
evidence • Based on a consensus
• Rapidly evolving definition of
• Outcomes oriented “effectiveness”
• Guidelines based • Fully integrated into
• Decision oriented oncology care delivery
systems
• Directly tied to payer
return on investment

17. EBM in Community Oncology Care
• Using EBM to advance the standard of care in a
community oncology setting blends:
ASCO
Research
Patient Payer
Dx & Rx
Therapy Authorization
NCCN Process
Evidence driven, Curative
consensus based
guidelines Adjuvant
Palliative Patient
CMS Progress
Determinations
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18. EBM in Community Oncology Care
Leveraging the power of EBM
1. Develop well defined policies based on recognized
protocols
2. Distinguish between accepted and acceptable
treatment protocols
3. Integrate oncology specialists into the authorization
process
4. Orient the Payer Rx authorization process to say
“yes”
5. Embrace advance care planning as an integral part
of the spectrum of patient care
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19. Leveraging the power of EBM
1. Develop well defined policies based on recognized
protocols
Situation
• Not all cancers have standard protocols
• 40% of Rx is off-label use
Opportunity
• Develop policies based on peer-reviewed literature,
for example:
– Prophylaxis of CINV based on emetogenic potential of
chemotherapy agents
– Erythropoiesis-Stimulating Agents (ESA)
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20. Leveraging the power of EBM
2. Distinguish between accepted and acceptable
treatment protocols
Situation
• Erythropoiesis-Stimulating Agents (ESA)
• Some health plans only authorize FDA approved package insert
dosing schedules
Opportunity
• There are many acceptable alternative regimens
• Facilitate provider preference
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21. Leveraging the power of EBM
3. Integrate oncology specialists into the authorization
process
Situation
• 40% of Rx utilization in community oncology is off-label use
• EBM guidelines and standards of care are rapidly evolving
• Most community oncologists don’t have the opportunity to speak
directly with a peer when navigating the payer’s authorization
process
Opportunity
• Have oncologists with oncology practice experience and
knowledge of cutting edge EBM involved in the first line
authorization review to accelerate P.A. resolution and patient
treatment
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22. Leveraging the power of EBM
4 Key Steps to integrating oncology specialists into the authorization
process:
1. Oncologist as initial reviewer
– Compliance
• Health plan
• National oncology guidelines
– Regimen
• Therapy appropriate to disease staging
• Treatment length
2. Oncologist & oncology pharmacist collaboration
– Preferred drug list
– Dosage appropriate to patient height and weight
– Dose optimization to prevent wastage and to promote cost effectiveness
3. Inclusion of a 2nd community oncologist as a 2nd level review prior to any
recommendation for an authorization denial
4. 3rd level academically based reviewer is available at health plan’s
request
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23. Leveraging the power of EBM
4. Orient the Payer Rx authorization process to say “yes”
to appropriate care
Situation
• Most Rx authorization gatekeeper processes are designed to save
money by saying “no”
Opportunity
• Standards of care vary by practice
– Authorization process facilitates advancing SOC
• “Please educate me”
• Leverage technology to provide empowering information
– Internet based systems
– Authorization processing information
• Diagnosis & staging
• Regimen info & patient history
• J-Codes
• EBM Literature references
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24. Leveraging the power of EBM
Benefits From Orienting the Payer Rx
Authorization Process to Say “Yes” to
Appropriate Care
• Appropriate Patient Care
– NCIS experience: 1 denial in 2 years
• Wrong drug for stage of disease
• Denial upheld by health plan

25. Leveraging the power of EBM
5. Embrace advance care planning as an integral part of
the spectrum of patient care
Situation
• End of life care is one of the most costly stages of oncology care
Opportunity
• Do the right thing
• Incorporate EBM end of life guidelines into oncology practice
• Reimburse providers for appropriate:
– Palliative Rx
– Encounters: office/hospice/home
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26. Thank You
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27. About The Facilitator
• Dr. Myron “Mickey” Goldsmith is the Chief Medical Officer for New Century
Infusion Solutions (NCIS). NCIS is the first and only Integrated Single
Specialty Provider delivering full-spectrum solutions in the oncology care
market.
• A community based medical oncologist with over 25 years experience, Dr.
Goldsmith, has:
– Served as Executive Director of Development for the City of Hope
Oncology Network
– Consulted to many health plan, disease management and
pharmaceutical clients
– Authored many articles concerning clinical research in hematology or
oncology and several publications on issues of oncology managed care.
• Dr. Goldsmith was a graduate of Temple University and Temple Medical
School and performed his postgraduate training at the Graduate Hospital of
the University of Pennsylvania. He can be reached at
mgoldsmithmd@newcenturyinfusionsolutions.com
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