St. Charles Health System struggled to reconcile the administrative burden and reimbursement structure of Medicare Advantage (MA) plans. Examples of this burden included:

• One MA plan with 5,000 lives in-network at St. Charles returned 1,200 denials in one year — and 75% of them were overturned upon appeal by St. Charles.¹
• Clinicians had to account for an average two-week delay for prior authorizations when creating treatment plans and scheduling patients. These delays were not only burdensome for all patients, but especially problematic for cancer patients who require timely care.

As a result, St. Charles dropped three MA contracts. St. Charles considered dropping additional MA plans, including the health plan involved in the pilot, which would have resulted in St. Charles going out of network for over 15,000 additional MA patients. However, St. Charles Health System reached an agreement with the health plan that kept St. Charles Health System in-network. Part of that agreement included a revamped prior authorization process for patients receiving care at St. Charles Cancer Institute.

St. Charles Cancer Institute has demonstrated success in care quality through their stringent NCCN guideline adherence for the past 20 years. While Dr. Linyee Chang, senior medical director of cancer services, championed her program and its evidence-based care, executive leadership had not previously pursued performance-based rewards from health plans.

St. Charles Health System is a private, nonprofit organization based in Bend, Oregon, and operates four hospitals and a large, multi-specialty physician group. The Cancer Institute offers medical and radiation oncology services and has multiple accreditations. The Cancer Institute earned the 2018 Outstanding Achievement Award by the Commission on Cancer of the American College of Surgeons.²

Both St. Charles and their health plan partner use NCCN guidelines as the standard for evidence-based cancer care, resulting in alignment on the ideal care pathway to optimize clinical outcomes.

St. Charles Health System and the health plan used quality- and data-driven discussions to develop an instant authorization pilot program for cancer care. Rather than removing authorizations entirely, St. Charles and the health plan negotiated specific criteria that merit near-instant approval through a different pathway on the same physician portal. Their alignment on evidence-based NCCN guidelines allowed them to reduce administrative burden and improve timeliness of care.

Successful development and implementation of the pilot required three key actions:

1. Document adherence to evidence-based guidelines.
2. Translate clinical excellence into “win-win” contract standards.
3. Adapt workflow to meet current contract requirements and prepare for the future.

While the pilot is in early stages, St. Charles has collected promising metrics on approval rates and wait times. Of the 93% of chemotherapy care regimens that adhere to I or IIA NCCN categories, 91% are approved within a day.¹ St. Charles is working with the health plan to address process glitches and get that number closer to 100%. Patients and providers have reported better satisfaction, especially around improved care timeliness. In Q3 of 2024, only 3% of cancer patients waited more than ten days for a prior authorization, down from one-third in 2023. St. Charles Cancer Institute reported zero denials from their health plan partner in 2024, inclusive of all cancer patients.¹

This collaborative pilot was a crucial part of the contracting discussions that resulted in St. Charles Health System remaining in-network for over 15,000 Medicare Advantage members.

Going forward, St. Charles leadership intends to pursue similar instant authorization programs for all service lines that demonstrate a consistent focus on quality outcomes and align with the established clinical guidelines accepted by both providers and payers.