Guidelines and Pathway: Link to Benefit Design by Employers

Kristin Jarrell, PharmD; Michael Toscani, PharmD

September 2016, Vol 7, No 8 - Employers’ Perspective


In today’s changing oncology landscape, the quality and value of cancer care have become increasingly integrated. With the rising costs of cancer treatment, payers and policymakers aim to better define value, as well as to educate patients about their therapeutic options.1 Insurers and payers have implemented a variety of strategies to control costs at the behest of employer plan sponsors, including utilizing oncology clinical pathways.

Clinical Pathways

Oncology pathways are clinical decision support tools that are created with evidence-based guidelines and literature to shape effective, tolerable, and least costly treatment options for a cancer diagnosis.2 Distinct from clinically established guidelines themselves, pathways are more limited in treatment sequencing and are often driven by payers, although there are provider-initiated pathway programs. Clinical pathways can be a contentious issue in oncology, because payers have embraced them as tools to marry cost-effectiveness with evidence-based medicine.2

Some advocates of the new paradigm claim that clinical pathways will optimize patient care and may also reduce costs, and help guide oncologists to the best evidence-based treatment decisions.2 Supporters of clinical pathways tout the model as a stellar means to achieve the Triple Aim of healthcare reform—improving outcomes and quality, improving the patient experience, and lowering costs.3

However, detractors of the clinical pathways approach criticize it as being too confining for their practice and their patients.2 The art of medicine remains a strong component of practice today, just as technology and medical innovations increasingly expose the science, yet knowledge gaps persist.

Employer plan sponsors, as influencers and drivers of health insurance management, need to understand all aspects of clinical pathways across plan stakeholders. As high-deductible plans, shared-risk, and direct contracting continue to remain the status quo, it will be necessary to properly position such tools in alignment with employers as purchasers of care to establish a benefit design strategy.

The History of Pathways

With increasing healthcare costs and changing reimbursement models, payers and providers have sought ways to optimize care outcomes and to manage costs. In the past decade, one popular approach to managing healthcare costs has been the implementation of clinical oncology pathways.4

In 2008, CareFirst BlueCross Blue­Shield of Maryland implemented a plan-sponsored pathway in conjunction with P4 Healthcare, paving the way for a plethora of pathway users, such as WellPoint, which launched a nationwide pilot plan in 2014 to incentivize oncologist adherence to cancer care pathways.5,6 Even public agencies such as the Centers for Medicare & Medicaid Services are considering adopting such programs, depending on the preliminary success of the pioneering pilot programs.7

The Controversy

The most common argument in favor of clinical oncology pathways is the associated cost-savings that result in decreased spending.8,9 Proponents of clinical pathways contend that such configurations help to manage drug utilization in an era of bundled payments. Furthermore, clinical oncology pathways avoid laborious preauthorization, and streamline an otherwise lengthy process, thereby optimizing the provider’s time as well as the patient experience.9

In addition to expediting the overall process, clinical pathways also allow for third-party payers to gather disease stage and biomarker data, and to better assess risk adjustment, where insurance claims data alone may be inadequate.9

Despite the potential advantages of clinical pathways, some providers are reticent to adopt this new reimbursement method and are slow to accept a clinical pathways model.4 Critics of the concept underrate it as “cookbook medicine” and overly limiting to their practice.

In addition, because clinical pathways consider the population at large when incorporating cost into treatment algorithms, critics of the model assert that it opposes the idea of personalized medicine.5

Furthermore, some experts argue that there are too many inconsistencies with the use of clinical pathways. If clinical pathways are built on evidence-based medicine, then different organizations’ pathways should all be fairly similar, which is not always the case. Sometimes, the provider may have to use several pathways to diversify patient options, which can be extremely difficult to monitor.3

The Future

Although it remains to be seen how acceptance of clinical pathways will influence the future of cancer care, it is important to be informed about these treatment and reimbursement models. Because of their ability to leverage evidence-based guidelines as well as cost considerations, clinical pathways will likely continue to gain momentum in cancer care, as oncology practices evaluate and utilize these methods.

When appropriately used, clinical pathways may offer enhanced patient care, lower administrative burden and healthcare costs, and optimize outcomes. Additional real-world research will further shape the utility of clinical pathways in today’s oncology practice. Employer plan sponsors and their representatives need to be educated on such tools, and are invited to participate in the process to avoid benefit design conflicts.




References

  1. IMS Institute for Healthcare Informatics. Innovation in cancer care and implications for health systems: global oncology trend report. May 2014. http://obroncology.com/imshealth/content/IMSH_Oncology_Trend_Report_020514F4_screen.pdf. Accessed August 5, 2016.
  2. Rinde M; for OncLive. Oncologists say clinical pathways are too confining. September 10, 2015. www.onclive.com/publications/oncology-business-news/2015/September-2015/oncologists-say-clinical-pathways-are-too-confining. Accessed March 7, 2016.
  3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27:759-769.
  4. Gesme DH, Wiseman M. Strategic use of clinical pathways. J Oncol Pract. 2011;7:54-56.
  5. Wong W. The evolution of clinical pathways for oncology. J Clinical Pathways. 2015;1:37-42.
  6. Avalere Health. New WellPoint program will pay physicians for adhering to oncology pathways. June 11, 2014. http://avalere.com/expertise/life-sciences/insights/new-wellpoint-program-will-pay-physicians-for-adhering-to-oncology-pathways. Accessed August 5, 2016.
  7. Mehr S. Is Medicare ready for oncology clinical pathways? Am J Manag Care. 2014;20:SP57-SP58.
  8. Kreys ED, Koeller JM. Documenting the benefits and cost savings of a large multistate cancer pathway program from a payer’s perspective. J Oncol Pract. 2013;9:e241-e247.
  9. Polite BN, Page RD, Nabhan C. Oncology pathways—preventing a good idea from going bad. JAMA Oncol. 2016;2:297-298.