Written by Mary K. Caffrey; Produced by Nicole Beagin
Clinical care pathways in oncology have been discussed for some time as a strategy for controlling healthcare costs. These “road maps” guide the treatment protocol depending on how the disease progresses. Pathways have supporters and opponents, but they are gaining notice: WellPoint announced a $350 per patient per month incentive on May 27, 2014, in The Wall Street Journal1 during the annual meeting of the American Society of Clinical Oncology (ASCO) in Chicago.
WellPoint’s pathways initiative began in 6 states on July 1, 2014. With that effort set to begin, The American Journal of Managed Care convened a panel, with voices from the payer and provider realms, to discuss how pathways are changing cancer care. Seema Sonnad, PhD, associate editor and director of Health Services Research at The Value Institute at Christiana Care Health System, led the discussion.
Joining Sonnad were ASCO President Peter Paul Yu, MD, who is director of cancer research at Palo Alto Medical Foundation; Jennifer Malin, MD, PhD, medical director for Oncology Care Management, WellPoint; Chadi Nabhan, MD, FACP, associate professor of medicine, hematology and oncology section, and medical director, Clinical Outpatient Cancer Center, University of Chicago; and I.W. Tischler, MD, national medical director, oncology, Cigna.
When the president of ASCO says that healthcare spending is “unaffordable” and “unsustainable,” it’s little surprise that both insurers and leading physicians are looking for ways to bend the cost curve. In cancer care, clinical pathways are gaining ground among payers and some providers, although how well they will work and how much they will save remains unknown.
“We have an unaffordable, unsustainable healthcare system,” Yu said at the start of the discussion, describing the challenge that confronts cancer care. With an aging population, the prospect of more cancer patients, and new, expensive drugs to treat them, how does the system allocate limited resources? “We need to get a handle on the rising costs of care,” he said.
What are pathways? Nabhan said there’s a “gray area” between clinical guidelines, such as those developed by the National Comprehensive Cancer Network and ASCO, and pathways, which account for real-world situations like side effects, and, of course, the cost of therapy. Not all pathways are alike, the panelists agreed; some direct toward a “single best treatment,” while others offer 3 to 4 options. And, once a patient progresses past second- or third-line therapy, the judgment of the oncologist starts to replace the protocols. Pathways are still a new concept, and several speakers credited US Oncology with both pioneering the concept and publishing data from the experience.
Pathways differ from guidelines in that they confront cost, a factor that physicians historically avoided; it was not considered ethical to do so. But with the rising costs of cancer care, and the out-of-pocket expenses patients face, doctors and health plans have little choice. The new term “financial toxicity” refers to the effect that these burdens have on patients, and their families, as they undergo treatment. Yu and Tischler agreed that oncologists had to be good stewards of this realm. “This is going to enhance the patient experience,” Tischler said. “We are really stewards not only of our individual patients, but of the population as well.”
Pathways seek to reduce the variability out of the system, not only to control cost, although that is a goal, but also to improve care by bringing more focus to evidence-based guidelines, panel members agreed. That said, pathway compliance will never be 100%, nor should it be; each patient is different, and pathways must provide enough leeway for clinicians to tailor treatment toward individual needs and responses to treatment. The panelists agreed that about 80% compliance to predetermined pathways could be expected.
Yu called for improvements in technology, and better integration of electronic health records with pathways, which he said would allow oncologists to record why they deviate from pathways. This could lead to more frequent updates and improvements in care.
What will make pathways successful? Payer and provider representatives on the panel agreed that “buy in” from treating clinicians was crucial. “You have to have people believe that it’s a transparent process of pathway development that they respect and feel they had a voice in,” Yu said. Whether institutions use pathways developed by an outside vendor or build them in-house, it’s essential to have representation from “across the spectrum of academic and community medicine” of care, he said. “That helps build trust into the decisions,” said Yu. He believes that the medical literature doesn’t always reflect the reality on the ground, and providers can bring that reality into pathway design.
Malin said WellPoint considered using an outside vendor for its pathways but ended up using in-house expertise, consisting of oncologists and pharmacists, who developed the protocols in a process not unlike that used to place therapies on a formulary. Internal teams of oncologists and pharmacists put together summaries based on efficacy, quality of life, and cost. The external advisory group members came from community and academic oncology practices, including National Cancer Institute–designated institutions, she said. WellPoint’s pathways are available through an online portal, and forms of feedback come both weekly and quarterly, Malin said.
The essential element of WellPoint’s program is that it offers rewards, not penalties, Malin said. If providers deviate from the pathway, which is anticipated, “They will still get reimbursed,” she said. “But if they are on the pathway, (they are eligible for) additional reimbursement for treatment planning and care coordination.”
Yu said incentives are preferable to penalties at this stage, since pathways are new. “You’re trying to change people’s thinking in a positive manner,” he said.
What about the most expensive drugs? Malin said that while WellPoint’s pathways plan aims to bend the cost curve, it will not keep cutting-edge therapies away from patients if the evidence shows they save lives.
“Our pathway is about rewarding quality care,” she said. “We’re not going to exclude something from the pathway simply because it’s more costly. Pathways, like the rest
of clinical medicine, is an iterative process—a groundbreaking therapy that is going to change the care for a large percentage of patients with a particular tumor type—that would need to be put in the pathway right away.” By contrast, a therapy that would only affect a small share of patients would be added more slowly; for other therapies, as evidence accumulates, a therapy may have better or worse toxicity or effectiveness, and thus may be added or dropped, Malin said.
Among the challenges, and opportunities, of pathways is the fact that the evidence needed to include therapies in practice might be based on different criteria than in a clinical trial. More emphasis might be placed on toxicity and other side effects, or on “value,” which involves survival-versus-cost calculations, and that’s where judgments get complicated.
“You can’t exclude an expensive drug just because it’s expensive,” Nabhan said. His main concern is that it can take time to gather evidence to determine the value of a new therapy; what is the right amount of time to include a drug in the pathway?
Yu emphasized that pathways must be dynamic, living vehicles that are constantly revised to include new findings. This is where better integration with technology will be critical, he said: if a regimen that was well-followed suddenly falls out of compliance with the pathway, it would be an indication that there’s a new study that should be reflected in a pathway update.
As Nabhan noted, “We don’t have a metric to decide, ‘What is the cost of one life saved for how long?’ We really don’t—that is the elephant in the room—it’s critical to address at some point.” EBO