A discussion on how patient preference, including geographical difficulties, can impact treatment compliance with payer policy, and whether there might be intervention to meet 80% compliance.
Steven Peskin, MD, MBA, FACP: Joyce, you mentioned that the pathways were designed to be reasonable for 80% adherence and that there are those patients who for whatever reason, and often patient-specific issues—they live so rural that a regimen that requires weekly administration is not going to work for them, whatever it may be.
Two things: One is, is the patient preference an impact on adherence, and then for those individuals, those physicians, the individual physicians who are not able to achieve that 80% adherence, is there any engagement from a higher level in the practice to try to rein in their complaints?
Joyce A. O’Shaughnessy, MD: The first question about patient preference is very important, and it’s critical, and that is a reason to deviate from the pathway. For example, there are women, and Bill has seen this many times as well, there are women who have received a diagnosis of breast cancer who will decline curative therapy because of unwillingness to have alopecia. Now they have some scalp cooling but it’s not covered by insurance as of yet. And it’s costly, so it’s not available to everyone. So to be able to substitute an agent, a chemotherapy agent, thankfully these are oftentimes old generic drugs. They’re not very expensive but they’re still off pathway; to avoid alopecia and save a life—got to do it. You know what I mean? And so there’s an example where patient’s preference is front and center—got to do it, you know? And so it’s great. That’s why the flexibility is there.
In terms of the situations where people’s practices don’t allow them to stay within the parameters, you know, I think it’s 75%. I’m somebody who has to deviate quite a bit. I see complex metastatic patients and they’ll be on their 10th line and there isn’t anything on the NCCN [National Comprehensive Cancer Network] Guidelines for 10th line. So I’m off label. Like I said, thankfully a lot of these things are not very costly, they’re old generic drugs. But still, they’re off pathway.
I’ve not had a problem. And I have to be quite flexible sometimes. I’ve never had a problem staying within the 75%, or whatever it is. I think that for doctors who really are falling out, I think they have to look at what’s going on here with their particular patient practice. You know, is it something that they aren’t really aware of—the different options that they can use within the pathways. It’s kind of unusual that people are way off the reservation these days. I really don’t think so.
There are definitely educational processes. And I think ultimately there could be financial implications just in terms of shared governance within large practices where decisions have been made that with regard to bonus structures or any kind of profit sharing, that there could be some diminution of that for people who are way out there, who are, if you will, going their own way. I’m not aware that that happens. It hasn’t come to my consciousness and my universe of the people I work with. But I suppose it happens in very large practices.