Published Online: May 18, 2012
Bruce A. Feinberg, DO; James Lang, PharmD, MBA; James Grzegorczyk, MS, RPh; Donna Stark, RPh, MBA; Thomas Rybarczyk, RN, BSN; Thomas Leyden, MBA; Joseph Cooper; Thomas Ruane, MD; Scott Milligan, PhD; Philip Stella, MD; and Jeffrey A. Scott, MD
Despite rising medical costs within the US healthcare system, quality and outcomes are not improving. Without significant policy reform, the cost-quality imbalance will reach unsustainable proportions in the foreseeable future. The rising cost of healthcare in part results from an expanding aging population with an increasing number of life-threatening diseases. This is further compounded by a growing arsenal of high-cost therapies. In no medical specialty is this more apparent than in the area of oncology. Numerous attempts to reduce costs have been attempted, often with limited benefit and brief duration. Because physicians directly or indirectly control or influence the majority of medical care costs, physician behavioral changes must occur to bend the healthcare cost curve in a sustainable fashion. Experts within academia, health policy, and business agree that a significant paradigm change in stakeholder collaboration will be necessary to accomplish behavioral change. Such a collaboration has been pioneered by Blue Cross Blue Shield of Michigan and Physician Resource Management, a highly specialized oncology healthcare consulting firm with developmental and ongoing technical, analytic, and consultative support from Cardinal Health Specialty Solutions, a division of Cardinal Health. We describe a successful statewide collaboration between payers and providers to create a cancer clinical care pathways program. We show that aligned stakeholder incentives can drive high levels of provider participation and compliance in the pathways that lead to physician behavioral changes. In addition, claims-based data can be collected, analyzed, and used to create and maintain such a program.
(Am J Manag Care. 2012;18(5 Spec No. 2):e194-e199)
The overall incidence of cancer in the United States is projected to increase by 45% in the next 2 decades from 1.6 million in 2010 to 2.3 million in 2030. Direct medical costs associated with cancer are also projected to increase exponentially from $104 billion in 2006 to more than $173 billion in 2020 as a result of increases in both the cost and quantity of cancer therapies.1 Newer cancer treatments are not only likely to be more expensive than the existing standard of care, but they will expand the pool of available treatment options.2,3 Despite these rising medical costs and treatment options, quality and outcomes are not improving.4 Without significant policy reform, the cost-quality imbalance will reach unsustainable proportions in the foreseeable future.1,4-6
Many factors play into the rising costs of healthcare, including an aging population, an expanding arsenal of therapeutics for chronic disease states, increasing regulatory demands on stakeholders, inefficiencies in delivery, and archaic information technologies. All of these factors result in significant variations in practice patterns among medical oncologists.7 Costs can vary dramatically because physicians often treat patients with the same condition differently in choice of drugs, referrals for surgery and radiation, referrals for palliative and end-of-life care, and types of supportive care. Strategies such as prior authorization and decreasing fee schedules have been implemented in an effort to lower healthcare costs.8-10 However, because neither of these strategies addresses practice variances or the rapidly rising cost of cancer therapeutics, their impact on healthcare costs has been of limited benefit and brief duration.11
Clinical pathways are a method to reduce unnecessary and costly treatment variation; however, physician participation is crucial for their success.1,12 The perceived challenge of cookbook-style medicine to physician autonomy from an external authority, such as insurance companies or academic advisory boards, can be one barrier to pathway adoption among others such as time constraints and comfort with previous practice patterns.13,14 Without accountability or incentives, physicians might comply partially with the terms of a pathway program or not participate at all. Therefore, a collaborative effort between pathwaydeveloping parties and oncology groups is needed.15 Physicians directly or indirectly control or influence the majority of cancer care costs.1 Therefore, physician behavior change can be used as a surrogate marker of cost savings, which can be difficult to demonstrate as a result of evolving patterns of care, new drug technologies, patent expirations, and data capture problems from revenue code and charge bundling to name a few.
This article details a collaborative statewide cancer clinical pathway program in which provider network medical oncology physicians played an integral role in developing oncology clinical pathways. The success of the program was determined by evaluation of physician compliance to the pathways and their behavioral changes in the first year of the program resulting from the inherent difficulties in determining cost savings in this setting.
Collaborative Clinical Pathway Program
In mid-2009, 3 groups—Blue Cross Blue Shield of Michigan (BCBSM; Detroit, Michigan), a large single-state not-for-profit BCBS plan; Physician Resource Management (PRM; Novi, Michigan), a state physician organization; and Cardinal Health Specialty Solutions (CHSS; Dublin, Ohio), an oncology benefit management company (previously P4Healthcare)—partnered to develop a clinical pathway program whereby physicians would jointly develop the content, structure, and implementation of the program pathways. Involving physicians in the clinical pathways development process would provide an incentive for physicians to participate in the pathways themselves. Care pathways for breast, colon, and lung cancer were developed in the first year of the program and expanded by 5 additional malignancies in the second year. The program would benefit all parties involved in patient care, including patient, provider, and payer, by aiming to improve the consistency and quality of patient care while also reducing costs. The clinical cancer care pathways program was operated and funded through the Oncology Physicians Resources (OPR; West Bloomfield, Michigan) group, an existing statewide physician-owned general purchasing and management organization and subsidiary of the Michigan Society of Hematology and Oncology (MSHO; Rockingham Royal Oak, Michigan). PRM is an administrative arm of OPR and would manage the BCBSM pathway program.
Before the development of this partnership, BCBSM instituted a pay-for-performance program in 2005 for Michigan physicians, the Physician Group Incentive Program (PGIP). This program added a physician organization fee component to each professional service payment. The physician organization component was held in an incentive pool and fully distributed twice each year to physicians who participated in PGIP. It was determined that the BCBSM cancer clinical care pathways program would be placed under the aegis of PGIP and that funding would be paid directly to OPR/PRM according to PGIP bylaws. Figure 1 presents a schematic of steps involved in the pathways development and the implementation of BCBSM oncology treatment pathways.
Alignment of Stakeholders
One of the first critical steps in the development of the BCBSM pathway program was to align stakeholder incentives so that all interests would be taken into account. BCBSM wanted to develop a program that would improve clinical outcomes with more predictable costs, thereby bending the cost curve downward for future oncology care. Oncologists wanted reimbursement stability. CHSS wanted to prove its value-added benefits to the process by not only receiving a fee for service for their technical support but also sharing in both the upside and possible downside of the program results attributable to pathway compliance. All 3 stakeholders agreed that, given the appropriate incentives, provider behavior could be modified in a self-governing process in which claims data would be used to monitor compliance.
Provider Incentive Program
PRM and BCBSM agreed on ways to reward physicians for using pathways. BCBSM provided each physician participant a $5000 payment for the first year of the pathways program to cover any extra costs involved and to provide a financial incentive to participate and meet approved compliance thresholds. In addition, the reimbursement rate for several generic therapies associated with the specific clinical pathways was increased to remove the perverse incentives created by average sales price–based reimbursement (13 drugs were modified in 2010). Evaluation and management codes would also be increased (10%) for pathway program participants as a result of compliance in year 1. Payments were also made to PRM to serve as the coordinating center for this statewide effort from the BCBSM PGIP incentive pool. With those monies, PRM elected to make payments to physician groups for their participation, support the development of clinical pathways, provide software developed by CHSS, and subcontract with CHSS for additional services. BCBSM incentives and fee schedules were also reviewed to assess how payer incentives aligned with best practices.
PRM selected regional leaders to serve on a steering committee. The steering committee comprised 12 regional network oncologists from academic-based practices and large and small community-based practices. It was cochaired by the CHSS chief medical officer and an OPR officer as nonvoting members. On the basis of published scientific and clinical evidence and national guidelines, the steering committee developed the most up-to-date and effective oncology care pathways for breast, lung, and colon cancer and supportive care using granulocyte colony-stimulating factors, erythropoietin stimulating agents, and antiemetics. Treatment, efficacy, toxicity, and cost (in that order of priority) were considered in all pathway regimen selections. National Cancer Institute–designated clinical trials and/or decisions for palliative care were mutually agreed upon to be included in all pathways. The steering committee also embraced molecular diagnostics in breast, colon, and lung cancer as part of the pathways process.
The oncology pathways were introduced to the remaining oncologists within the broader BCBSM network for their review and input. All recommendations were evaluated by the steering committee. These steps were critical and ensured that the valuable experience and expertise of each network physician was considered before pathway adoption. The pathways are organized by line of therapy, and they include molecular profiling, histologic profiling, treatment indication, and stage. The steering committee continues to meet quarterly and on an ad hoc basis as needed.
Before the pathway finalization, the criteria for selection and protocols underwent review by BCBSM; however, BCBSM did not play a role in protocol selection. It was determined from the beginning of this partnership that this statewide initiative was best positioned for success if BCBSM kept its role to that of an objective third-party funder with a strong interest in the outcomes of the program but with no direct influence in the determination of what ultimately constituted the clinical pathways.
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