The 2007 annual meeting summary of the Institute of Medicine (IOM) succinctly highlighted the issue of variability in care. “Studies repeatedly show marked variability in what healthcare pro viders actually do in a given situation. [By following evidence-based practice], there is an untapped potential to reduce healthcare costs and improve quality.”1 In the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st Century, one of the 10 axioms for the redesign of our healthcare system called for evidence-based decision making. “Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.”2
Today in oncology, we have an opportunity to test the hypothesis that reducing variability in patient care (eg, by adherence to guidelines) improves quality and lowers cost. Oncology is perfectly positioned for this, owing to the regularly updated practice guidelines documenting the strength of the evidence that underpin the recommendations. These include guidelines from the National Cancer Institute/Physicians Data Query, American Society of Clinical Oncology, National Comprehensive Cancer Net work, and others. Evidence-based medicine benefits all 3 constituents in cancer care and brings the payer and provider into alignment for the right reasons. The physician has a credible basis for the treatment options and recommendations in discussions with the patient; the patient can feel confident that the treatment he or she has decided upon is the best for them; and the health plan is paying for medically necessary and appropriate care, whether an established standard chemotherapy regimen, supportive care drug, or a clinical trial. The potential risks and benefits of the particular treatment are quantifiable from published data. This is the first step in improving quality, and physician registries and payer databases are analyzing this information in retrospective and prospective fashion.
Although it seems intuitive that practicing evidence-based medicine will reduce ineffective prescribing (ie, overdosing, underdosing, and evaluate the value of comparable but not identical therapies. Even more difficult is the untenable choice for patients to decline treatment they cannot afford.
Manipulating drug reimbursement schedules. Payers are exploring equalizing the financial incentives to oncologists between higher cost single- source agents and lower cost multisource agents. This approach does make sense in that it removes the financial disincentive for oncologists to use an equally efficacious multisource drug where it might be appropriate. But, taken by itself, this tactic does not go far enough in defining optimal and least toxic care for patients that will drive better outcomes and present fewer complications. It will not address appropriate use of therapeutics in second-line therapy and beyond. And it will not drive the application of personalized medicine to distinguish patients who benefit from targeted therapies from those who only experience toxicities and cost.
If managed care tools are not the answer, what is the way forward? Pathways are the medically appropriate, sensible, and sustainable strategy to address the unnecessary variability and uneven quality in cancer treatment and thereby improve quality, decrease potential toxicities and side effects, and moderate costs. Pathways will actually improve the value of cancer care from the inside out.
1. Institute of Medicine. Evidence-Based Medicine and the Changing Nature of Health Care: 2007 IOM Annual Meeting Summary. Washington, DC: National Academies Press; 2008.
2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
