Late in 1997, when Bruce Ross told me that Bill McGivney would replace him as CEO of the National Comprehensive Cancer Network, I thought the recruitment made sense.
McGivney, then vice president for clinical and coverage policy at Aetna Health Plans, was one of my go-to sources on politically charged issues of the day, including policy for payment for high dose chemotherapy and bone marrow transplantation in breast cancer and the ill-fated healthcare plan put together by then First Lady Hillary Clinton.
I was disappointed to see Ross, a friend and a long-time source, leave NCCN. (He needed a kidney transplant.) But if anyone at that time really understood payment policy, it was McGivney.
“I am interested in learning new things,” McGivney said to me when I called him for an on-record chat. “This is an opportunity to work with the premier institutions, to apply my knowledge of the inner working of managed care, contracting with major institutions, technology assessment, development of coverage policy, outcomes research, and development of public policy.
NCCN, an organization holding its 25th annual conference this week, was founded with the goal of promulgating practice guidelines based on the standards of care provided at elite academic institutions in the U.S. (The Cancer Letter, March 15, 1996).
- The first story in the four-part series on NCCN appeared in The Cancer Letter and the Cancer History Project two weeks ago (The Cancer Letter, March 5, 2021).
- Last week, The Cancer Letter and the Cancer History Project published a conversation with Robert C. Young, one of the founders of NCCN (The Cancer Letter, March 12, 2021).
- Next week: an interview with Robert W. Carlson, NCCN’s CEO since 2013.
At the time McGivney came to NCCN, off-label uses of drugs were reimbursed by Medicare and most insurers only if those uses were mentioned in at least one of the three compendia.
The words “three compendia” became something of a mantra in the cancer world in those days.
Alas, at least one of the compendia wasn’t doing well, and there were signs of trouble from others. “I had actually worked on AMA Drug Evaluations at the AMA, so I was familiar with the compendium process,” McGivney said to me in a recent interview. “They fell to the wayside, interestingly, or began to, in the 1990s, just when they were being recognized by legislation regulation, so it was crazy.
“As payers started to use the guideline recommendations more, I said, ‘Well, we need to facilitate this for payers, because they’re mainly interested in drugs and biologics and off-label use. What we’re going to do is we’re going to develop our own compendium, and develop a nice comprehensive, logical listing of indications and other information that quickly the payers can look up and they can make coverage determinations much more easily, again, based on what NCCN says.’
“Hence, in 2005, we started to develop the [NCCN] Drugs and Biologics Compendium, and on Jan. 16, 2008, my good friend Lee Newcomer at UnitedHealthcare, came out with a press release that said, we will basically pay for drugs based on the NCCN Compendium, if they are Category 1, 2A or 2B.’ That was that. In June of that year, Medicare recognized the NCCN Compendium, and then eventually all the private payers did as well.” (The Cancer Letter, June 6, 2008).
What’s the difference between a practice guideline and a compendium listing?
“The NCCN recommendations and the guidelines are just faithfully, accurately, and completely transitioned and transposed and translated into the compendium format, so that’s why, when you’re anybody, but if you’re submitting from a drug company perspective, you’re submitting to the NCCN Guidelines to get recommendations specified,” McGivney said.
“Then, those are just transitioned to the compendium format, but as you know, the compendium format was recognized legally, so we wanted to get that format and be recognized by Medicare.”
A video recording of our conversation is posted here.
A transcript follows:
Paul Goldberg: You joined NCCN right after Bruce Ross; so, let’s do the timeline.
William T. McGivney: Actually, I remember, it was Martin Luther King Day in 1997. I had been at Aetna for just around six years, specifically running a number of areas, most conspicuously, or importantly, the whole coverage area, both on the medical side and also the pharmacy side.
NCCN actually came in to see me in August of 1996.
This is before I really even knew what NCCN was. Actually, Bob Young came up with an outside consultant, and Sara Perkel, who was at the time the COO of NCCN. She had been there about a year. Bruce Ross hired her.
PG: Basically, I heard from Bruce Ross that you were going to be his designated, or handpicked, or chosen successor. By then, I probably had known you for maybe at least five or six or seven years, maybe longer. I think I probably knew you before Aetna.
PG: So, let’s do a bit of prehistory, because I think that leads into everything.
WTM: It was interesting, because Aetna was undergoing changes. They had purchased U.S. Healthcare, a small three-state HMO plan, and Aetna wanted this group to take all of Aetna over, not just the huge health plan that we had.
So, things were in turmoil there. I was thinking at the time of starting my own consulting company. As people said, “You’re the only one that has the experience you have in terms of your background in actually deciding coverage about everything from a drug to an artificial heart.”
I was thinking about that, and I had an offer to go in with a company, but for me there wasn’t equity, so I was thinking about going on my own. Then NCCN met with me.
A headhunter called me and said, “Would you be interested in this NCCN?”
I said, “Well, yeah, I’ll look into it.”
I didn’t actually expect it would happen, but it did.
PG: You were one of the pioneers of technology assessment, to the point where when Bruce told me they were hiring you, I said, “Yeah. Whom else are you going to hire? This guy knows what he’s doing.” Can we talk a little more about bone marrow transplant for breast cancer?
WTM: That was just an intriguing issue. Actually, I started to get involved in the controversy way back when I was at the American Medical Association, where, to your point, I set up what was called the Diagnostic and Therapeutic Technology Assessment Program at AMA, which actually became quite influential, including over payers specifically.
Bone marrow transplant was a huge issue, even back then.
Then, when I basically got recruited to Aetna, it was just intriguing, because the major thing Aetna was interested in was basically, I had written a lot about how you manage and how new technologies really evolve, specifically into appropriate use and practice.
One thing they had on their minds at Aetna was this whole bone marrow transplant issue, because it turns out, I went there in ‘91 or ‘92.
On the first Monday of my job they informed me that Aetna was going to be on 60 Minutes, having turned down a bone marrow transplant. It was actually the second time that this story had been run on 60 Minutes. It was actually run a third time, despite my being on, as I always say, for 90 minutes with 60 Minutes, explaining the whole new process I set up, which was the model that was used across the country, including [being] written into law in the State of California.
Bone marrow transplant was a huge, controversial issue in the 1990s, and we were just right in the middle of it at Aetna.
PG: Well, you had Grace Powers Monaco [a childhood cancer advocate who founded Candlelighters Childhood Cancer Foundation and who was involved in several other childhood cancer organizations]. You suggested to her that she set up a business, essentially, which was…
WTM: She set up the business later… So, Grace was a wonderful person. I had known her, and I know you know her well. I had called her up, and I said, “Grace, I got this problem, this issue here. I think I have an idea of how to fix it, or address it.”
I got on the train and went down to Washington. I met with her. In my book, it talks about how she said after a few minutes, “Yeah, you’ve got a big problem there,” but we worked it out, and a lot of it was her idea in terms of saying what we did was we basically took every bone marrow transplant case, and we didn’t make any judgment yes or no with Aetna, and we turned them all over to her.
And she picked independently three of the world’s leading docs in the U.S. We never said whom to pick or not to pick… Many of them turned out to be NCCN docs, and if one out of three said, “Yes, it’s okay,” then we covered the transplant.
It was a very effective process that we set up, and extremely fair.
You couldn’t get more fair, but obviously you were dealing with patients with severe life-threatening illness. Anyway, that’s how Grace and I got together.
That was a major issue, which took up a major component of my time at Aetna, but also threw Aetna into the national spotlight.
PG: This was before… By the time you got to NCCN, bone marrow transplant for breast cancer was pretty much settled, and NCCN had an idea…
WTM: Not quite.
PG: Yeah, yeah, not quite… Tell me…
WTM: It was still fulminating out there, but it was probably settling down a little, and that was ‘97. To the point it was as you know, in 1999, it was when six or seven U.S. docs went over to South Africa and wanted to see the data. I’m blanking on the doc from South Africa’s publication.
PG: Werner Bezwoda.
WTM: Yes. And there was no data. He made it all up, so that was the issue, and to NCCN’s credit and Bob Carlson was chair of the Breast Cancer Panel.
NCCN, from the provider perspective, had been maintaining [that] for breast cancer autologous bone marrow transplantation with high-dose chemotherapy was investigational, when actually national Blue Cross Blue Shield had decided that it should be covered.
There was certainly great credit due to the Breast Cancer Panel at NCCN for sticking to their guns and basically saying, we don’t have the data, and the small bit of data that was being used to support bone marrow transplant in breast cancer turned out to be totally false.
PG: It was amazing to see that play out—the insistence on data. Of course, NCI was at the time running the “high-priority trials.”
WTM: It was just interesting, because I was involved in that, too.
I became quite friendly with Bob Wittes when he ran [Cancer Therapy Evaluation Program] at NCI, so every once-in-a-while, when I was at Aetna, he would call me down, I’d go down to Washington, and I’d just tell the folks there what Aetna was doing, and what we were thinking specifically.
To your point, he said, “We can’t accrue enough patients to do the clinical trials.”
They had two national clinical trials on BMT [with] high-dose chemotherapy in breast cancer, but they couldn’t accrue enough patients, because there was so much support for it out there as being standard of care, patients didn’t want to be randomized.
PG: What did you see as a potential? Why did you accept the NCCN job, because you had other options. What was good about it?
WTM: It was just interesting. I was really going back and forth in terms of starting my consulting career back then.
I would say one of the major drivers was a personal one, in the sense that my wife was from Philadelphia, and her father had just died of bladder cancer, and her mother was down there. It got us down to Philadelphia.
Specifically, so as I say, I was going back and forth. Not the mission, but the strategy of NCCN just was not clear enough. But eventually I just said, “Look, obviously, who would not want to have the opportunity to work with these great institutions specifically and try and build something?”
PG: Well, there was Joe Simone. There was Bob Young. There was Bruce Ross.
WTM: The only time I spoke with Joe Simone, God bless him, was when he interviewed me in Washington after the executive committee had interviewed me.
Just an aside, I went to the Hilton Hotel in Chicago, where the NCCN was having its board meeting.
I was walking through the lobby to go to the meeting room, where I was going to meet with this executive committee. There was Alice Gosfield, who I knew. “Hey, what are you doing here? Etc., etc., etc.”
I walked into the room, and it was like 86 degrees, no exaggeration. I thought, “Oh well. I’m done. I’m going to be sweating like a whatever by the end of this,” but God was with me. It turns out, I guess, they thought I’d be a good person to take over the NCCN, because [as] I later found out, that institutions were concerned that nothing was happening at NCCN, and they were paying substantial dues every year.
A couple of the major institutions were threatening and voicing that they might withdraw from NCCN.
PG: Well, the organization was set up for a certain set of goals, which were—if I remember correctly, I’ll probably forget one—one of them was managed care. That was the urgency, the DRGs.
WTM: No, managed care.
PG: Managed care under the Hillary health plan.
WTM: There was this headline across The Wall Street Journal: “National Cardiovascular Care Network Established.”
I know it generated a lot of interest at Aetna.
I was the one that was running, specifically, the whole Organ Transplant and Bone Marrow Transplant Network, so, actually I was tasked with setting up National Cardiovascular Care Network.
I think that generated a lot of interest across the NCCN institutions in saying, “Look, we’re the best institutions, best hospitals in the country for cancer treatment and care. We should set up a similar national network.”
I think that was one of the main reasons for the formation of the NCCN.
Now, I’ll just add something; then I’ll stop… At Aetna, I, being on the medical management side, was negotiating contracts, including rates at big institutions, including MD Anderson.
I think it was a bad strategy, bad idea for NCCN to have a national network, because I think the bottom line, if you’re looking at MD Anderson, MD Anderson is not going to want Bill McGivney or anybody else from something called NCCN to negotiate what reimbursement they’re going to get for their services.
PG: There’s also a possibility of antitrust issues, and so forth.
WTM: Yeah, that’s a good point.
PG: So that [goal] didn’t pan out and the danger went away as Hillary’s health plan went away, too.
PG: So, the urgency is gone. The second reason was, of course, the guidelines. That was alive.
And the third reason was pie in the sky: being able to show that academic cancer centers provide better value than community care, which is a difficult thing to prove, even if true.
WTM: It’s difficult to prove, and it’s also a political issue, because here maybe not so much end of the ‘90s, but certainly in the early 2000s, these big academic centers were trying to compete with each other and were setting up these networks in the community.
I know, for example, if you look at the Boston membership for NCCN, it’s Mass General and the Brigham, and Dana-Farber, so it’s a trifold membership. If you look at it, there was this whole big competition between Mass General and Dana-Farber about setting up their own community networks.
So, they’d be trying to convince certain community practices to join the Dana-Farber network or the Mass General network, etc. There were always these internal issues that would stress somewhat the whole concept of having a united NCCN.
PG: By the time you arrived, the biggest threat had gone away. Maybe it’s a couple years before. Then, the rest is just these two things that are pretty nebulous, and the money comes in from dues only.
PG: Then you come in and you see opportunities, ta-da…
WTM: Well, yeah. Rodger Winn, the father of NCCN guidelines, was just a terrific person. He had the foresight and understanding that, first of all, if you’re a breast cancer doc or a lung cancer doc at an NCCN institution, you know the data, the guidelines, the trial design backward and forward.
The audience that needed guidelines from a group like NCCN, clearly, were the community docs, because the community docs maybe treated at that time eight to 10 types of cancer, and to keep track of all the data, as the data was accelerating and advances were accelerating, was going to be extremely difficult.
The second component was he understood [that], unlike other organizations, you don’t need to have this glorified, sophisticated, super-methodologically-oriented process, where, for example, you have to do a total organized systematic literature search.
He understood, as I say, that the docs who were sitting in that room knew the literature cold, and they could come in, and then they could develop the guidelines and update them as further data proceeded, so he designed the whole process, so it was extremely reasonable, fairly not expeditious but timely and certainly an efficient process in terms of getting recommendations out to the target audience and in a manner and a format that was clear to the target audience, i.e. the community docs that they needed.
PG: Who comes up with that plan? I thought it was Bob Young and Rodger Winn.
WTM: Well, it was Rodger Winn. I wasn’t there, but when they were talking about why to form NCCN; you are correct.
The second issue was development of guidelines. Guidelines, as you know, was a hot thing, because 1987, Bob Wennberg, up there at Dartmouth, published his articles about the inappropriate and medically unnecessary procedures going on, and how we needed guidelines.
A lot of groups, for example the American College of Cardiology, the American Heart Association, had guidelines in 1991, well before the NCCN, but that was a basis as you said for starting the NCCN.
This is before I got there. The person they tasked with that was Rodger Winn, who was down at MD Anderson, but who had been recruited from MD Anderson. He was a community oncologist up there in New Jersey.
He had the clarity of vision not to make this too complex, and again, put it in a format that directly communicated the information and recommendations to those who needed it most, that is, community oncologists.
PG: Is that still used, by the way, his approach to expert-based guidelines as opposed to-
WTM: It’s basically the way NCCN does it. I just remember, when I was there, we tried to make it a little more systematic. “Why don’t you make it systematic, so that it’s even more similar across panels?”
I just said, “You know what? That’ll destroy the whole effort.”
These panels, some do have the different personalities.
There might be a greater acceptance, if you will, of abstracts versus publications, but you know what? It basically churned out and updated in an amazing fashion, so that they were up to date. If something came out, and when I was there, I would actually walk the halls…
For example, a drug or biologic, within two weeks of approval might be, or usually was, in the NCCN’s Drugs & Biologics Compendium with an NCCN recommendation.
PG: Just looking back… Before NCCN, if you got a particular disease, you went out and found a luminary, who knew exactly what to do, and that would be in a major cancer center, possibly in Boston, possibly in New York, possibly in Houston, and a few others, but NCCN is something else. It’s more like, “Here it is, this is the treatment you would get from one of the luminaries, so go next door.”
WTM: Exactly. It was just interesting, because the first guideline was released in 1996. It was the breast cancer guideline. I was not at NCCN yet, but by the early 2000s, what was happening is clearly they were becoming the standard of care out there.
What we saw was that the payers started to use them.
I remember I would get emails from Aetna asking me or saying, “This is our interpretation of the NCCN recommendation here,” when they were trying to establish a coverage policy. “Is this correct?”
So I said, “You know, we’re up to this.” I would write back. I knew what they were doing is they were establishing, not an excuse, but basically establishing a firmer platform upon which to set coverage policy, because if somebody questioned them, they could always just point and say, “Well, NCCN says…”
But that was important, because that was the start of what I think was the most significant action or event that happened while I was at NCCN: payers increasingly used it, even [before] the establishment of the Drugs and Biologics Compendium, but increasingly used NCCN recommendations to set coverage policy.
What we did is we turned the tables 180 degrees, in the sense that as the payers were assuming more authority and telling the docs what to do, in oncology the NCCN panels were telling the payers what they should do and what they should cover.
PG: But they were paying you in order to be able to use your guidelines.
WTM: The payers? No. No, I wanted them to use the guidelines. That’s why the guidelines were available free of charge.
PG: You have to have a license to use them?
WTM: The issue was, with the payers we wanted them to use them, so while I was there, we were just encouraging them to use them and take the recommendations.
I think, actually, if you look at that scroll that runs under the NCCN, I don’t think there is any major payer—by that I mean, Aetna, Cigna, United—who basically pay the NCCN to use the guidelines to establish coverage policy.
And that would be on purpose, because otherwise, what are the NCCN guidelines?
Importantly, they’re two things: They represent the standard of care, and, secondly, they drive coverage policy with payers. We want the payers to use them.
I wouldn’t want any hindrance whatsoever put in the payers’ way, because that would basically diminish the influence that the panels in the NCCN had on behalf of patients and docs.
PG: But the money [flow] has changed. The dues became a small part of the NCCN [revenues]…
PG: That was something that changed. Where did the rest of the money come from?
WTM: Most of the money came from the biopharma industry. They were always interested in having the NCCN recommendations communicated, particularly, obviously, to other docs, to constituents, and they supported all sorts of educational events.
Two things: we did that and, obviously, we had and still have the conflict of interest policy, in terms of transparency and in terms of which docs work with which companies, and setting limits on how much money panel members, for example, can have, but I think it’s interesting in the sense that big newspapers would ask me, call me up [and ask], “Well, what about this?” To get down to a discussion about, “Well, they provide a cup of coffee to somebody.” You’ve got to be kidding me.
I would say, “Look. This is a free market. We have a product. We are explicit about how the guidelines are developed. We’re explicit about where NCCN money comes from, all our educational grants and things like that, and we put them on the market, and all the payers use them, so if somebody else comes up with a better idea on how to do it, then let them come to the marketplace and take our place.”
Then the second component was, I remember being at an NCCN annual meeting, we were doing one of the Cliff Goodman [of Lewin Group] roundtables. So, I was in the audience. They were talking about this and that… Someone brought up biopharma money, and all this for educational…
A previous year, I said to myself, “I’ve had enough of this,” so what I did is every time we sent an application for an educational grant to a pharma company, we sent the same grant request to what do you call it, big managed care companies… United, Aetna, all of them.
As I got up in the audience and said, “You know, we had a perfect record. We submitted 35 grant applications to the major payers, to the United States for educational events, and we had 35 that were declined. So what do you want me to do?”
PG: I’m going back to your first day at NCCN. At that time, there are three compendia that are used to determine what gets paid for and what doesn’t get paid for.
PG: Here we’re talking about reimbursement of off-label uses, so here are these three compendia, and then they start falling by the wayside.
WTM: They do.
PG: Go ahead.
WTM: I had actually worked on AMA Drug Evaluations at the AMA, so I was familiar with the compendium process.
They fell to the wayside, interestingly, or began to, in the 1990s, just when they were being recognized by legislation regulation, so it was crazy. As payers started to use the guideline recommendations more, I said, “Well, we need to facilitate this for payers, because they’re mainly interested in drugs and biologics, and off-label use.
“What we’re going to do is we’re going to develop our own compendium, and develop a nice comprehensive, logical listing of indications and other information that quickly the payers can look up and they can make coverage determinations much more easily, again, based on what NCCN says.”
Hence, in 2005, we started to develop the [NCCN] Drugs and Biologics Compendium, and on Jan. 16, 2008, my good friend Lee Newcomer at UnitedHealthcare, they came out with a press release that says, we will basically pay for drugs based on the NCCN Compendium, if they’re Category 1, 2A or 2B. That was that. In June of that year, Medicare recognized the NCCN Compendium, and then eventually all the private payers did as well.
PG: How long did it take?
WTM: It took a while.
PG: I ran into you at ASCO one year, and that was several years before, and we were trying to figure out what is the difference between [a] compendium and guidelines. Maybe we should recreate that.
WTM: The NCCN recommendations and the guidelines are just faithfully, accurately, and completely transitioned and transposed and translated into the compendium format, so that’s why, when you’re anybody, but if you’re submitting from a drug company perspective, you’re submitting to the NCCN Guidelines to get recommendations specified.
Then those are just transitioned to the compendium format, but as you know, the compendium format was recognized legally so we wanted to get that format and be recognized by Medicare.
I spent about two years walking the halls of Congress talking to some very smart people and some very young people. I was always amazed. You’d walk in and you’d have some very smart, at least book-smart 23-year-old sitting there, obviously just listening to you, because that was what he or she was required to do, so at least you’d think that you had a hearing in that congressperson’s office, but anyway, we walked the halls.
Eventually, certainly CMS knew that we were walking the halls.
At the same time, I was talking with private payers, and as you know, the good Doc Newcomer was always extremely progressive.
He and I were talking, so the NCCN compendium became the basis for UnitedHealthcare coverage.
PG: That was the beginning?
WTM: They were the first one, but as I say, six months later, Medicare came on board, too, and then everybody piled on.
PG: I only know of one compendium that’s left.
WTM: No. There are four others, but NCCN is preeminent.
Then there was this rush to be in NCCN compendium, so some of the commercial entities that had always just put out drug information did it, so I think this AHFS DI, the Hospital Formulary people, but they’ve been around for years, and then there was Micromedex, but then there were a couple new ones.
One called Clinical Pharmacology, which was just a publication. Then there’s another one that I can’t recall, so there are now five Medicare recognized drug compendia, but again, the NCCN is preeminent in terms of its influence.
PG: What do you think is the percentage of use? There’s probably no way to calculate there or is it?
WTM: One thing that’s interesting, and the Good Doctor Carlson told me that NCCN had over 10 million downloads of its guidelines worldwide, which is just incredible.
When I was there, I think were right around five million, so it’s doubled, but it just shows you just the extent of utilization and application of NCCN guidelines. There’s tremendous use of the Drugs & Biologics Compendium by payers. I just know that for a fact, but I can’t quantify it for you.
PG: It’s a fascinating thing, because here’s an organization that’s set up for these three goals. One of these goals goes away. Another goal is met.
A third goal is a little harder, showing that you do better than community practice, especially considering that your Number One user is community practice, so, things change in a very interesting way, and this thing adapts. Then the compendia situation, that really is a re-formatting—literally a re-formatting.
WTM: I think I was good at going with the flow, because I always say, “Hey, look. I’m the lowest common denominator in the room here.”
A president-elect of ASCO said to me once, “You know, we just had a board meeting at ASCO. They said that move to make the guidelines a drug compendium was brilliant.”
I just looked at her and I said, “I guess so. I never thought of it as brilliant. I was just sitting there one day saying, ‘This just makes eminent sense to do this. Put it in a format that payers use.’”
I think that was key, and it was always like trying to go with the flow and see strategically from an academic perspective, but also, really, from a business perspective, what was going to be best for the institutions as members, for the docs, and for the patients, because, as I say, we were in a situation where that transition to managed care making the decisions in the 1990s was just not the right way to go. We took it back from them, and it’s still back.
Ira Klein at Aetna called the NCCN guidelines a 50-lane highway.
I actually was flattered by that, in the sense that it showed that indeed all appropriate options were being considered and recommended by NCCN experts, and that the payers then were making those options available generally, if you will, to docs in a shared decision-making process with patients. I actually put it in a very positive light, because I thought it as important that again, docs make the decisions.
They know the data. NCCN recommends, and, basically, it’s available, because the payers have decided they’re going to use NCCN to make coverage policy.
PG: But philosophically, also getting at how medicine is practiced, just that move from a luminary to a very large number of people who can provide systematic quality care that provides very similar outcomes, right?
WTM: It was important and Rodger Winn was a wonderful gentleman.
He was like a Renaissance man. My wife has called me the least curious PhD in the world, and, actually, she’s correct, but the point being is Rodger was a Renaissance man.
I think his years in community practice and just his wide variety of interests really brought him to the right place in terms of how to set up a guideline process that was really valuable, just in terms of clinical decision-making.
The payer concept was more me, but Rodger is the father of NCCN guidelines. He was wonderful.
PG: I think your wife might be incorrect in that.
WTM: I’ll tell her. You’ll be in trouble.
PG: I will be in trouble, but I think she might be wrong on this one, because you’re maybe very focused on things, but you were clearly seeing opportunities.
WTM: No, no, no. Again, I had it in my head. The Aetna days were very formative for me in the sense that, and you know it’s in the book, but I’ll tell you that…
At the end, one of the things they gave me, because I always would get these problem areas, because I actually did fairly well at Aetna.
At the end, they gave me this group of seven doctors, who would have to make the final decisions, because all denials had to be by an MD.
I got this group, and it was like this group of docs, not to be ageist, but who were like 61 to 79 years old, were like ENT docs, and this kind of doc, and that kind of doc. They all thought that they had won the Nobel Prize, or were close to it.
They were willing to make decisions in oncology and all sorts of fields they knew nothing about.
I just looked and I said, “This is not the way. I do not want for a loved one or for myself a doctor like this to have any influence on what’s available to me or my family or my loved ones as patients.”
That really drove me at NCCN in terms of we’re going to take back the night, so to speak in terms of the docs are going to have more and more influence, and I’m going to strategize and work with the board and with these great doctors to determine how we do that. We found our way.
PG: You mentioned your book twice now.
WTM: Yeah, I’m promoting it to you. I’m sorry.
PG: No, no. For the record, we might as well talk about your book, because it’s very interesting. I’ve read the draft, I will confess. Now I will disclose, rather, and I thought it was really fascinating to read it, and thank you for letting me see it. What are your plans with the book?
WTM: Oh, I don’t know. For right now, as you know, it’s sitting in abeyance. Yeah, let’s go back to it.
It was formative for me, because, as I talk about a lot of organizational policy groups, for me it was different than any other payer even, because for me, my group set what the policy was across for the patient population, for the beneficiaries of Aetna, but at the same time, I, for some reason, as a poor PhD, ended up deciding case after case that was always on the edge, and almost usually involved a patient who would die and might die anyway, but who would die but needed the opportunity, in certain cases, to have a certain type of therapy available to them.
As I’ve said to you before, it was exhausting and exhilarating.
I woke up half of my nights in a cold sweat literally. It’s true because I always had one of those cases on my mind, driving back and forth to work, at work, and as I slept.
It also drove me at NCCN, because I said, the more we saw the good experts, the KOLs who should decide what appropriate care was gain leverage, establish the standard of care and then gain leverage and influence with the payers, the more I wanted to make sure that was concrete and finalized.
PG: I think your book is a fascinating historical document, which the Cancer History Project would love to publish.
WTM: Well, we should talk about that, because it’s just sitting there, and I haven’t got time. Anyway…
PG: I wouldn’t have brought it up, but you forced me to… If we were to look at NCCN and your experience there as a case study, what’s there to be learned? What’s the take-home? You’re now being a business professor more than the guy who made it happen?
WTM: I think the take-home was, people to the day still tell me. “Gee, I was surprised they hired you from Aetna.”
I didn’t grow up in the cancer community. I did have a medical background at AMA, but I brought this perspective that was strategic in terms of I don’t know if I call it a business sense, because I don’t consider myself a businessperson, but strategically in terms of, as I just talked about, how decisions are made and how to insert an organization like NCCN into the nexus, or the nucleus, of decision-making specifically.
The other thing that I was fortunate is to have people like Bob Young. Bob was elected chairperson in 1997, and he was chair for four years. It’s a three-year position, but what happened was, Margaret Tempero was lined up … She was the vice chair … to be the next chair, and then she ran and became president-elect of ASCO, so Bob had to hang on for another year, but Bob was right across the street almost, at Fox Chase, because our offices were in Philly.
We would go over, and the two of us have these staccato conversations, because Bob’s emphatic, and I’m somewhat emphatic, but you know what?
Bob would give me his direct opinion, but I got to do what I thought was right, with the oversight of the board.
When I got to NCCN, I think NCCN was at such a place that the board members in general were happy to have somebody who had ideas about where to take NCCN. Generally, they were quite supportive, and I wouldn’t say I was totally free, but I had a lot of latitude, if you will, to do what I thought was best for the organization.
PG: Is there anything we forgot? Anything we missed? Anything you’d like to add?
WTM: Well, one thing I will add is, because I was anticipating, so what was the best thing about NCCN?
It was the staff we assembled. You talk about a staff that was committed to improving… Usually there’s a lot of bullshit. Everybody says … Well, I won’t go on, but you look at all the stuff on the websites. It’s like, “We’re dedicated to patients and this and that.”
This staff truly was, at NCCN, and still is, dedicated to bettering things for patients. It was just a wonderful staff, and the one thing I will say about them, they had what I always called a sense of urgency.
If the NCCN panel met, they wanted those recommendations in the compendium as quickly as possible so the payers who were looking at the compendium would see them and then have to follow them.
As I say, and even at conferences. They were just so customer-oriented. We would always get great reviews of what they did at the conference.
I have one great story, if I can tell it the right way. In terms of registration for the conference, we had this room where stuff would come in. In the old days, faxes and things, so this fax came in.
The paper was blank, and the doc called up and said, “I just want to make sure you just received my registration for the conference.”
The woman, the NCCN person who retrieved the fax, and it was blank said, “No, no. Just fax it again. What I just received is blank.”
He faxed it again, and it’s blank again. He calls up and she says, “No, no. I think we have a problem with our computer on our end. Just turn it over and see if that works,” so she knew what he was doing wrong, but she put the blame on NCCN. That is the classic story about NCCN staff in terms of customer-oriented and being, as I say, just wonderful people and just dedicated, and as I say, having that sense of urgency that you need to make any group successful.
The other thing that we did, and we were business-oriented, that other not-for-profits really don’t do is we executed. By that, I take that in the positive sense. We got things done. We didn’t wait around. We didn’t dilly-dally.
As I say, I was fortunate with Bob Young and others, David Hohn, etc., to have the great support as chairs just to get things done, and it worked.
PG: It clearly did. That’s worked for 25 years.
WTM: Well, what was it? It was started in 1995, so you’re absolutely right, going on 26 years. It’s good stuff, and I was there for 15 of them. It was a great time.
As I say, we got a lot done. It was formative. Everything leads. Aetna was formative for NCCN, and NCCN has obviously been quite important to what I’m doing in consulting, and Aetna was important, because we do a lot of work with payers, etc. It’s all good, and I’m still ticking.
PG: Well, that’s wonderful. Thank you so much for talking with me.