Our proprietary evidence-based guidelines assure that patients receive appropriate care while reducing inappropriate spending, unnecessary exposure to radiation and injectable drug side effects. The guidelines are fully transparent and available to health plans, providers and members. The guidelines are derived from evidence-based research, industry-approved practices, peer-reviewed literature, and published criteria from specialty societies:

• American Society for Radiation Oncology (ASTRO)
• American College of Radiation Oncology (ACRO)
• American College of Radiation Oncology (ACRO)
• American Cancer Society
• European Society for Radiotherapy and Oncology (ESTRO)
• American College of Radiology
• Centers for Medicare and Medicaid Services
• National Comprehensive Cancer Network

Radiation therapy has contributed significantly to the rising cost of treating cancer, with utilization increases on the order of 20% and greater for certain leading cancer types over a 10-year period. The introduction of costly advanced technologies – despite offering enhanced safety and efficacy – are estimated to contribute to a 45% increase in utilization of radiation therapy over the next 10 years, accompanied by dramatically escalating costs. Nearly two-thirds of all patients with cancer receive radiation therapy during the course of their treatment. This percentage represented approximately 1.5 million patients treated with radiation therapy in 2011, and this figure has likely risen in more recent years with the increasing incidence of various cancers and significant technological advancements. As the potency of radiation therapy increases, so too does the propensity for serious adverse events and harmful errors when these therapies are not employed cautiously and judiciously. Payers and physicians also face challenges in keeping up with the latest medical evidence for radiation therapy, and high cost oncology and adjunctive therapy drugs.

Care to Care provides a comprehensive utilization management program designed to ensure that radiation therapy and drug treatments provided to our members is delivered consistent with nationally recognized clinical guidelines, allowing payers to reduce inappropriate medical expenditures. Radiation and medical oncology pathways that drive clinicians toward the most clinically appropriate treatment protocol are provided. The pathway system provides authorization for a course of treatment by looking at the therapies that control disease best, offer the best chance of cure, and limit toxicity while improving patient quality of life. If two or more courses of therapy are similar in terms of outcomes, the treatment offering less toxicity is recommended. If two or more therapies have similar outcomes and toxicity, the lowest-cost alternative is recommended. Utilization management program is delivered via a peer to peer review process by radiation and medical oncology specialists for treatment plan and coverage. Our peer review process does not impose restrictive regulatory guidelines that interfere with the process of care or undermine the ability of radiation oncologists to individualize patient treatment. Our program is transparent, evidence-based, and unobtrusive to the doctor-patient relationship, and provides for education and continuous quality improvement.

Care to Care’s oncology capabilities can be combined with its effective diagnostic imaging management services. Ordering physicians follow the same process and work through the same contact center they currently use to request imaging exams, and they receive evidence-based medical criteria supporting best practices in radiation oncology. Providers submit procedure and treatment requests through the Care to Care portal. If the treatment meets evidence-based criteria, it is automatically approved by the call center staff. If the treatment falls outside of pre-set clinical guidelines, it is sent to a radiation or medical oncology physician for peer to peer review. The ROBM assures that patients receive the appropriate care without delay while delivering reduction in inappropriate oncology spending.

Care to Care’s value-added radiation therapy and medical oncology programs ensure that facilities follow best practices and deliver the highest quality of care through evidence-based medicine. Unexplained clinical variations in oncologist practice patterns are reduced through educational efforts that include evidence-based clinical practice guidelines. By improving patient quality of life, reducing toxicity, reducing doses to healthy tissue, reducing the need for supportive drugs, and reducing potential readmissions, these measures ensure that plans are “getting what they pay for” in terms of radiation therapy and medical oncology.