Care to Care continues to fulfill its vision of becoming a leading multi-specialty healthcare management firm, supporting educated, informed decision-making in radiology, cardiac imaging, radiation oncology, medical oncology, and referrals to specialists (Referral Guidance ™). We aim to enable our clients to make sure that their members receive the right test or treatment at the right time to achieve the best outcomes through the use of evidence-based medicine.
Care to Care’s Evidence Based Criteria Decision Support System for Imaging is a prior authorization tool designed to quickly identify studies ordered for medically appropriate reasons. It is not meant to be a complete compendium of proper indications for diagnostic studies, but rather a means to allow swift identification of proper use, in as broad a manner as possible, and with a minimum of interference with established routines at the ordering physician’s office. No tool can hope to cover every indication for imaging studies, the clinical circumstances and diagnostic questions that physicians confront every day are almost infinite in variety and complexity, so failure to appear in this tool should not be taken to mean that a particular sign or symptom is not a proper indication for a study. For this reason we view this tool as a perennial work in progress. All are welcome to contribute suggestions for additions, deletions and amendments, and those deemed to be sufficiently evidence based will be incorporated as soon as possible.
These criteria allow Care to Care to authorize the vast majority of appropriate requests at initial review. The remaining cases are then passed to one of our board certified radiologist physician reviewers. Using their experience and judgment they may authorize studies without further information, request additional data, or discuss the request with the referring physician in an atmosphere of mutual respect.
No request is denied without offering such a conversation.
Michael S. Komarow, MD, JD
EVP of Clinical Strategies
Care to Care LLC
Rachel Title, MD
Chief Medical Officer
Care to Care LLC
Care to Care’s Evidence Based Criteria Decision Support System for Radiation Therapy is a comprehensive utilization management program designed to ensure that radiation therapy provided to our members is delivered consistent with nationally recognized clinical guidelines. Radiation therapy 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. Our consultation model works collaboratively with providers to promote best practices for evidence-based use of radiation therapy. The criteria do not impose restrictive regulatory guidelines that interfere with the process of care or undermine the ability of radiation oncologists to individualize patient treatment.
Leonard Farber, MD
Section Chief
Care to Care LLC
The principles behind the formation of the Compendia and Criteria for Medical Oncology reflect the complex and changing landscape of therapeutic options available to medical oncologists. In some diseases, the use of molecular targets, the use of immunohistochemical analysis, and mutational analysis have already been placed in the therapeutic pathways based on Level 1 evidence. The list of actionable targets continues to grow along with the specific medicines targeting these markers. The objective of Care to Care’s guidelines is to allow the highest degree of quality care that should be offered to patients based on evidence based data. Pathways and guidelines that allow for the best patient care are offered, while at the same time being cognizant of the cost of medicines and the options that can be used with less expense medicines without compromising patient care. Sometimes this can be achieved by the preferred use of different agents and at other times, by the strategic sequencing of medicines to achieve optimal results with potentially less cost. Care to Care’s compendia offer physicians and patients cutting edge therapies while at the same time, being conscious of the cost of therapeutically equivalent less costly medicines. Because of the rapidly changing landscape and developments in medical oncology, Care to Care frequently monitors and updates its guidelines and compendia. These modifications will be based on newly published peer reviewed evidence based data. Even with its robust incorporation of the presently available data, Care to Care recognizes that the individual patient will have specific needs and circumstances. The Chief Medical Oncologists and his/her associates are always available to answer and discuss with physicians their concerns and the individual needs of the patient.
Francis P. Arena, MD FACP
Section Chief
Care to Care LLC
Care to Care’s Referral Guidance™ is a proprietary, web-based, clinical decision support system which provides guidance to Primary Care Providers (PCPs) in determining if a referral to a specialist is appropriate and complete. The program consists of problem and disease specific algorithms that are constructed from logic based questions derived from expert opinions, and best practice evidence based guidelines. Answering the questions will lead the physician to one of three end points: Recommended, not recommended, or deferred (until recommended tests, procedures or medications are prescribed or performed allowing for a complete work up prior to a decision to refer). The program is simple and quick to use, and available for 250 of the most common diseases or problems spanning 15 medical and surgical specialties. In addition to its screening function, the program also functions as an educational tool and clinical reference database through its disease specific pre-consultation evaluation subprograms lined to evidence based criteria to educate as to the optimal evaluation and patient management before treatment or a referral should be considered. Similar to our other programs, Referral Guidance is not meant to replace provider judgement but rather to support their decision making process.
Rachel Title, MD
Chief Medical Officer
Care to Care LLC