Pathways Creating More and More Value
Hollywood, FL—Pathways continue to be refined toward value-based care, adapting to the challenges of a rapidly shifting oncology landscape, as 2 speakers at the Third Annual Conference of the Association for Value-Based Cancer Care described.
Michael A. Kolodziej, MD, National Medical Director for Oncology Strategies at Aetna, Hartford, CT, and Marcus A. Neubauer, MD, Medical Director, Oncology Services, US Oncology/McKesson Specialty Health, TX, first discussed market pressures and the need to control costs.
Since 1996, the US gross domestic product has decreased by 2.4%, but healthcare costs have risen by 9.2%, and the cost of cancer medical care, as well as oncolytics, has increased by 15%. The fiscal future looks even bleaker, with cancer care costs projected to rise 39% by 2020. The consequence of this financial crisis is confusion by these market forces, Dr Neubauer suggested. “All stakeholders are struggling. Payers are struggling with rising costs and have problems getting their programs adopted by physicians. Physicians often have multiple platforms to manage. Employers are struggling with costs” (Figure 1).
In response, oncology management solutions are continuing to evolve, but this is creating a fragmented approach to quality. “We are not doing a great job solving this problem,” Dr Neubauer said.
Dr Kolodziej said that pathways are a way to carry out Aetna’s principles: to drive the efficient use of evidence-based medicine, to avoid waste and the misuse of medical services, and to leverage and integrate the many current and future medical and pharmacy cancer care initiatives.
As responsibility, risk, and accountability shift to the provider, pathways will become ever more important for communicating and measuring performance, Dr Kolodziej added. “They prove you are accomplishing minimal standards, but most important, they train oncologists to get in the mindset of measurements and process improvements. They are training sets for changing behavior.”
US Oncology/McKesson has responded by creating value-based pathways, believing that pathways can save money, without diminishing outcomes. Despite the size of the network—which includes more than 3000 oncologists, 2200 multispecialty practices, and 1.5 million patients with cancer annually—the pathways program is “very internal,” Dr Neubauer said.
“In our physician-driven program, all our pathways are designed by oncologists, with the intent of showing that we can achieve both value and a value-based contract with payers. We have had some success in this regard,” he noted.
Two recent studies provided proof of principle of this. Dr Neubauer led a study of patients with non–small-cell lung cancer that showed that on-pathway treatment saved almost $10,000—a 35% reduction—versus off-pathway treatment (Neubauer MA, et al. J Oncol Pract. 2010;6:12-18). Hoverman and colleagues (also with US Oncology) reached the same conclusions in their study of patients with colon cancer, where on-pathway treatment saved $50,000 to $60,000 per case, more than a 30% reduction versus off-pathway treatment (Hoverman JR, et al. J Oncol Pract. 2011;7(suppl):52S-59S).
Combining value-based pathways with additional services, such as advanced care planning and patient support services, resulted in a 12% cost-savings within The US Oncology Network, Dr Neubauer added.
Dr Kolodziej presented additional data on savings from 2 pilot studies, demonstrating that emergency department use and inpatient days steadily declined when pathways were implemented. “Both pilots are showing equal, if not better, clinical outcomes and patient satisfaction,” he said.
To further strive for value within a pathway system, US Oncology/McKesson has partnered with the National Comprehensive Cancer Network (NCCN), capitalizing on the individual strengths of each entity (Figure 2).
The Value Pathways are based on the NCCN Clinical Practice Guidelines in Oncology®—the gold standard for evidence-based oncology content—paired with quantified pharmacoeconomics, thus creating “Value Pathways that are powered by the NCCN,” Dr Kolodziej said.
“With this collaborative vision, we hope to create meaningful content and a technology standard,” he commented. “We can be universally recognized for driving quality patient care; we can provide increased value transparency for providers, payers, and employers; and our content can be integrated with physician work flow to enable programs across all providers and payers.”
Value Pathways will be administered via the NCCN’s new technology standard, Clear Value Plus, which is a program that integrates with patient workflow; imports patient and clinical data from frequently used electronic health records; identifies relevant Value Pathways and NCCN guidelines at the point of care; and allows providers, payers, and employers to align on quality and value.
“Clear Value Plus’s advanced, real- time reporting provides aggregate, actionable data for providers and payers,” Dr Kolodziej added. “Our primary customer is the physician, but we are showing this tool to payers too. We hope that physicians will be able to use this as their standard rather than having to participate in a number of different programs.”
Pathways must be adapted to changes occurring across the oncology landscape, he added, but there remain unanswered questions: With the growing availability of generic drugs, how will the “economic value proposition” be defined in a world with generic alternatives for which there is not much differentiation? How will pathways be designed for tumors that are defined more by molecular biology than by site of disease?
Discussion with the Experts
Dr Neubauer and Dr Kolodziej responded to questions from the Association for Value-Based Cancer Care conference audience.
Q: Can pathways affect the need for prior authorization for new drugs?
Dr Neubauer: Obviously, pathways must be relevant, and therefore must be able to incorporate new drugs quickly. But they must be evidence based, and we must consider all factors. If we don’t think a new drug is worthy, we won’t necessarily put it onto our pathway, even if it passes muster by the US Food and Drug Administration. If the drug is expensive and produces good results, yes.
Dr Kolodziej: When I joined Aetna a few months ago, one of the first things I did was review our oncology drug prior authorizations. We only require prior authorizations for 2 injectables, Xgeva and Aloxi. We don’t set that bar very high, but we do for orals, largely driven by their price tags. The beauty of pathways is that they eliminate administrative responsibilities that plans have to worry about, and they lessen the need for so many prior authorizations.
Dr Neubauer: But, payers do have to step in, in some way, although prior authorization is not a long-term proposition for anyone. We must develop a way to collaborate.
Q: The elephant in the room is the cost of the drugs themselves. Is the cost structure appropriate, and how can drug costs be controlled?
Dr Kolodziej: There are proposals on the table. The government may have to step in. Bundled reimbursements may have some influence, although I am skeptical. Great Britain has started value-based reimbursements, in which companies will be reimbursed only for the first 2 cycles if their drug does not seem effective. As we set up integrated delivery systems, pharmaceutical companies may want to come to those systems with value-based propositions, perhaps based on outcomes, and negotiate a price point over the drug’s potential value. That’s a pie-in-the-sky deal, but we have been engaged in discussions about this as an engine to drive the correct pricing of drugs. Of course, nobody wants to take that beast on. It’s a political minefield.
Dr Neubauer: I don’t understand how the government can reduce the bill for chemotherapy from average sale price (ASP) plus 6% to ASP plus 4%, but leave the ASP part—which the pharmaceutical company gets—unchanged. My opinion is that the government will start regulating prices as other countries do, or pharmaceutical companies will have to step up to the table. Pharmaceutical companies are starting to talk about value propositions, but these are early conversations and may not materialize.
Q: How useful are patient registries in producing meaningful data?
Dr Kolodziej: I take exception to the argument that we should have provider- or community-based registries to give us information about real-world experience. That’s not to say we cannot learn something from what functionally is comparative effectiveness research.
Dr Neubauer: Registries could be valuable, and there are efforts under way to develop them, such as American Society of Clinical Oncology’s CancerLinQ. But based on my efforts to try to analyze our own data, I can say it’s very difficult.