Streamlining Cancer Care in Michigan
Setting up a statewide cancer pathway program requires sophisticated data collection and analytic capability, as well as a collaborative mindset among participants, according to Kurt Neumann, MD, Medical Director of Managed Care and Quality Initiatives for the International Oncology Network, a division of Amerisource Bergen Specialty Group. Dr Neumann described the conceptualization and construction of such a program in Michigan during a session at the Managed Care Network meeting in Chicago, IL, on September 24, 2010.
In Michigan, as elsewhere, cancer care in the community setting is under financial pressure, Dr Neumann acknowledged. Adjuvant therapy is now used in more disease states for longer periods of time, in a sense turning cancer into a chronic condition. In addition, the rising expense of cancer drugs and the increasing number of cancer patients fostered by aging baby boomers will add further pressures.
Nevertheless, the community-based chemotherapy delivery system is incredibly efficient for patients and physicians, he argued, and allows for continuity of care. “It makes economic sense,” he said.
What Was Done
Dr Neumann described what he termed “a typical pathway project,” which originated as collaboration between many of the state’s oncologists represented by an offshoot of the Michigan Society of Hematology and Oncology (of which Dr Neumann is a longstanding board member) and Blue Cross Blue Shield of Michigan (BCBSM). Both parties recognized variability and cost issues pertaining to the use of chemotherapy, growth factors, hospitalization, and end-of-life care; the Michigan team addressed these by focusing on chemotherapy and white and red cell growth factors in cancers that comprised the majority of the drug spend (ie, breast, colon, and lung cancers).
An unusual feature of this pathway program, according to Dr Neumann, is that the physicians themselves were the drivers in setting it up, and that the contract is held by the physician group (comprised of nearly 80% of community oncologists in Michigan). An advantage of this approach is that care is not mandated by a third party, which has in turn led to great physician acceptance. The fact that multiple practices came together under state leadership is unprecedented, he emphasized.
The process began in the first quarter of 2009, with physicians generating a pathway/guideline program in collaboration with a third-party vendor and BCBSM. The first 3 months involved discussions and conceptualization on how the program should be formed. A 12-member steering committee representing both the major cancer centers and community physicians throughout the state hammered out the details of the program in approximately 2 months, followed by an additional month of legal review.
The program requires 70% physician compliance with the chemotherapy pathways and 80% compliance with supportive care (ie, growth factors and antiemetics). Physicians joining the program are paid $5000 up front to assist practices with covering applicable start-up costs, and they are able to earn additional monies if the program saves BCBSM money. Physicians joining the pathways program were cautioned, however, not to join the program for additional financial gain as that could not be guaranteed for a new program. Dr Neumann pointed out, “don’t join because you think you’re going to get a lot of money at the end of the year. This is a quality initiative.”
A key component of the pathway involves use of generics over branded medications when patient clinical outcomes are expected to be the same with either medication. Physicians are responsible for reviewing and modifying pathways quarterly or as needed, and physician groups are obliged to educate individual pathway outliers. Those individuals are given 2 quarters to come up to adherence or are removed from the program.
Initial Results and Future Directions
Early returns show physician compliance with the pathways at 80% to 90%. The high participation rate is encouraging, but it makes comparing results difficult— in effect, there is no control group. “Truthfully, I was amazed” at getting such a high level of participation, Dr Neumann confessed. “Before doing this, we had groups with 7 doctors with 7 different ways of doing things, and now we’ve gotten them to agree.”
Expected cost-savings from the pathway will derive from converting to generic use where appropriate, limiting lines of biologic therapy, and standardizing care. Calculating those savings, however, will be difficult. Currently pathways are financially vetted through checking remittance information, which spares practices from undertaking additional data collection, but this is not as sophisticated as what would be generated through electronic medical records, which have yet to be widely used. But these early steps allow payers to monitor physician compliance with pathways. Although there are no overall financial results so far, Dr Neumann cited published studies showing that nononcology patient care expenses have also decreased through adherence to pathways.
In the second year, the pathway program will expand to include lymphoma, myeloma, and ovarian and prostate cancers. Organizers will also de-emphasize the drug and reimbursement focus, instead having physicians concentrate on case-management issues to “better reward those who are more active in the program,” said Dr Neumann. Expanding pathways for diagnostics, endoflife care, and decision support is also planned, because these areas also involve wide treatment variability.
Setting up these types of programs requires sophisticated data and analytics, and that is where involvement with organizations with strong understanding of working with providers, payment methodologies, and proven technical abilities is beneficial, suggested Dr Neumann. A collaborative approach is helpful—in this case, the sharing of any cost-savings between the physicians and BCBSM was sealed with a handshake.
Dr Neumann foresees a transition to a population-based payment approach from the current episodic-based system, and this will depend on continued collaboration between payers and providers. An audience survey during the session indicated that 73% of attendees planned to implement pathways for outpatient oncology in the next 2 years; cost management was given as the key reason for implementing them.
“I’m convinced now that the physicians are willing to take on the task of being good stewards of the state’s healthcare dollars, especially if those dollars remain in the local healthcare system,” Dr Neumann said in closing