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Aligning Incentives: Quality of Care Initiatives and Precision Medicine

Keren Freydman, 2018 PharmD Candidate and Michael R. Page, PharmD, RPh
A 2007 economic analysis found that therapy guided by the Oncotype DX assay resulted in an increase of 2.2 years in life expectancy compared with tamoxifen alone and similar life expectancy to that seen with tamoxifen and chemotherapy.15

Clinical Pathways—Improving Quality and Decreasing Costs of Care

According to the results of a 2016 study, the costs of treating breast cancer can vary widely depending on the treatment regimen, regardless of the effectiveness of the regimen. Because at least 35% of patients with breast cancer will receive chemotherapy, an estimated $1 billion can be saved yearly by choosing regimens that are equally effective but less expensive.16

In comparing insurer costs, payments for patients who did not receive trastuzumab as part of their therapy varied by as much as $20,354, relative to the most common regimen, and out-of-pocket (OOP) costs varied by up to $382. For patients receiving trastuzumab as part of their treatment regimen, insurer costs varied by up to $46,936, with OOP costs varying by as much as $912 (Table 316).16 These large variations in cost arise from differences in the way oncologists practice with regard to drug choice, supportive care, and referrals to surgery, radiation, or palliative care. Health plans attempt to lower costs by establishing prior authorizations or decreasing fee schedules, but these strategies don’t address the differences in practices or the rising costs of cancer drugs.17 The implementation of clinical pathways, if developed effectively, has the potential to reduce costly variations in physician behavior.

Clinical pathways are evidence-based protocols and best practices developed to improve patient outcomes with the lowest cost regimens.17 Some barriers to the implementation of clinical pathways include clinician resistance to changing their practice, decreased autonomy in choosing treatment regimens, and time constraints. Physician resistance can be especially strong if treatment pathways are created by insurance companies or external third parties without clinician input.17

Based on a model implemented in a 2012 study, the first step to creating a pathway program is to take each party’s interests into account and align the incentives of all stakeholders, including oncology groups, payers, and pathway management companies.17 To be effective, the content, structure, and strategy for implementation of pathways should be developed through collaboration between physicians and pathway-developing organizations. Before implementing a pathway, it should be shared with all participating physicians so that their experience and expertise can be incorporated.17 Pathways developed for each specific diagnosis were based on current scientific and clinical evidence with consideration to efficacy, toxicity, and costs. All pathways were designed to include clinical trials, palliative care, and molecular diagnostics.17

Although the goal of clinical pathways is to reduce costly variation in practice, it is important to allow room for physician judgement and flexibility in treating difficult cases and addressing specific patient needs. As a result, compliance thresholds should be set, with reasonable expectations. An important aspect of the 2012 study was the inclusion of processes that allowed physicians to make appeals or requests for review, especially in advanced cases where standards of care are dynamic. Physicians participating in the study were given a lump sum payment to cover any added expenses and to provide an incentive to adopt and comply with the developed pathways.17 Practices such as use of appeals and lump-sum payments can play a large role in convincing physicians to participate in clinical pathways.17

Results of the 2012 study showed substantial oncologist behavior change and reductions in the variation of treatment delivery after implementation of a pathways-of-care program.17 Physician behavior change through pathways of care were predicted to decrease costs and were proven to lower the rates of emergency department visits and hospital admissions (Table 417). The total number of distinct treatment regimens used decreased from 168 to 136, with physician compliance increasing from 88% to 95% within the first year. Despite having over 120 unique combinations to choose from, physicians treated a majority of their patients with one of 30 regimens.17 Overall, the use of clinical pathways benefits the patient, provider, and payer by increasing quality and consistency of care while controlling costs.17

Current advances in technology and the introduction of new regulations, such as MACRA, in addition to the efforts of established organizations, such as ASCO and NCQA, are influencing the delivery and reimbursement of oncology care. Initiatives such as APMs, the OCM, and QOPI are aimed at improving quality of care while controlling costs. These goals are further made possible by the increasing availability of genomic targeted therapy and companion diagnostic devices, such as Oncotype DX, which allow physicians to better select the right treatments to match the needs of individual patients. 

1. Centers for Medicare & Medicaid Services. Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) incentive under the physician fee schedule, and criteria for physician-focused payment models. Office of the Federal Register website. federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm#print. Published November 4, 2016. Accessed June 2017.
2. Miller HD, Marks SS. A Guide to Physician-Focused Alternative Payment Models. Chicago, IL: American Medical Association; Center for Healthcare Quality and Payment Reform; 2015.
3. American Medical Association. Medicare alternative payment models. AMA website. ama-assn.org/practice-management/medicare-alternative-payment-models. Accessed July 20, 2017.
4. Centers for Medicare & Medicaid Services. MIPS improvement activities fact sheet. Quality Payment Program website. qpp.cms.gov/docs/QPP_2017_Improvement_Activities_Fact_Sheet.pdf. Published 2017. Accessed June 20, 2017.
5. National Committee for Quality Assurance . About NCQA. NCQA website. ncqa.org/about-ncqa. Accessed June 20, 2017.
6. American Society of Clinical Oncology Institute for Quality. Welcome to the Institute for Quality. ASCO iQ website. instituteforquality.org. Accessed June 20, 2017.
7. American Society of Clinical Oncology Institute for Quality. Quality Oncology Practice Initiative (QOPI). ASCO iQ website. instituteforquality.org/quality-oncology-practice-initiative-qopi. Accessed June 20, 2017.
8. American Society of Clinical Oncology Institute for Quality. Measures overview. ASCO iQ website. instituteforquality.org/qopi/measures. Accessed June 20, 2017.
9. American Society of Clinical Oncology. Quality training program. ASCO website. asco.org/training-education/professional-development/quality-training-program. Accessed June 20, 2017.
10. American Society of Clinical Oncology. ASCO CancerLinQ. CancerLinQ website. cancerlinq.org/. Accessed June 20, 2017.
11. American Society of Clinical Oncology. Guidelines, tools, & resources. ASCO website. asco.org/practice-guidelines/quality-guidelines/guidelines. Accessed June 20, 2017.
12. Nadauld L, Perkins B, Stone G, et al. A quality outcomes analysis following treatment with personalized genomic cancer medicine. Poster presented at: 2014 American Society of Clinical Oncology Quality Care Symposium; October 17, 2014; Boston, MA. Abstract 12.
13. Wurcel V, Perche O, Lesteven D, et al. The value of companion diagnostics: overcoming access barriers to transform personalised health care into an affordable reality in Europe. Public Health Genomics. 2016;19(3):137-143. doi: 10.1159/000446531.
14. Vijayaraghavan A, Efrusy MB, Göke B, Kirchner T, Santas CC, Goldberg RM. Cost-effectiveness of KRAS testing in metastatic colorectal cancer patients in the United States and Germany. Int J Cancer. 2012;131(2):438-445. doi: 10.1002/ijc.26400.
15. Genomic Health, Inc. Economic Validity and Implications. Redwood City, CA: Genomic Health, Inc; 2012.
16. The ASCO Post. ASCO 2016: significant cost differences found among breast cancer chemotherapy regimens. ASCO Post website. ascopost.com/News/41645. Published June 8, 2016. Accessed June 20, 2017.
17. Feinberg BA, Lang J, Grzegorczyk J, et al. Implementation of cancer clinical care pathways: a successful model of collaboration between payers and providers. J Oncol Pract. 2012;8(suppl 3):e38-e43s. doi: 10.1200/JOP.2012.000564.
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