Panel discussion: impact of guidelines on third-party payors and HMOs

Utilization management (preauthorization) has given way to disease management, i.e., the management, by providers in cooperation with third-party payors, of patients and their disease states from beginning to end. Managed-care organizations are seeking guidelines-based cancer disease management programs that result in: lower, more predictable costs; authoritative quality assurance; measured outcomes; reduced preauthorization disputes; and improved management of cases in clinical trials. Guidelines also need to provide some consistency and consensus regarding the management of common clinical problems. Good guidelines help assist managed-care companies gather data, build a more solid utilization management foundation and support a clinically sound disease management program. Aetna's Institutes of Excellence (IOE) program seeks to address the issue of coverage for high-dose chemotherapy and bone marrow transplantation, but can serve as a useful model for the development of comprehensive cancer networks.