AJMC Panel Asks: Does It Pay to Use Pathways?

AJMC Panel Asks: Does It Pay to Use Pathways?

PLAINSBORO, N.J. -- When the president of the American Society of Clinical Oncology (ASCO) says that healthcare spending is “unaffordable” and “unsustainable,” it’s little surprise that both insurers and leading physicians are looking for ways to bend the cost curve. In cancer care, clinical pathways are gaining ground among payers and some providers, although how well they will work and how much they will save remains unknown.

WellPoint’s May 28, 2014, announcement that it would pay oncologists $350 per patient per month to follow clinical care pathways gained notice in the cancer community and beyond, coming as it did during the 50th annual meeting of ASCO. With WellPoint’s effort starting this week in six states (effective date July 1, 2014), The American Journal of Managed Care convened a panel discussion of both payers and providers to discuss the usefulness and implications of pathways in cancer care. Seema Sonnad, PhD, the Journal’s associate editor and director of Health Services Research at The Value Institute at Christiana Care Health System, led the discussion, which can be found here.

Joining Sonnad were ASCO President Peter Paul Yu, MD, who is director of cancer research at Palo Alto Medical Foundation; Jennifer Malin, MD, PhD, medical director for Oncology Care Management, WellPoint; Chadi Nabhan, MD, FACP, associate professor of medicine, hematology and oncology section, and medical director, Clinical Outpatient Cancer Center, University of Chicago; and I.W. Tischler, MD, national medical director, oncology, Cigna.

“We have an unaffordable, unsustainable healthcare system,” Dr. Yu said at the start of the discussion, describing the challenge that confronts cancer care, especially: with an aging population, the prospect of more cancer patients and new, expensive drugs to treat them, how does the system allocate limited resources? “We need to get a handle on the rising costs of care,” he said.

What are pathways? Dr. Nabhan said there’s a “gray area” between clinical guidelines, such as those developed by the National Comprehensive Cancer Network and ASCO, and pathways, which account for real-world situations like side effects, and, of course, the cost of therapy. Not all pathways are alike, the panelists agreed; some direct toward a “single best treatment,” while others offer 3-4 options. And, once a patient progresses past second- or third-line therapy, the judgment of the oncologist starts to replace the protocols. Pathways are still a new concept, and several speakers credited US Oncology with both pioneering the concept and publishing data from the experience.

Pathways differ from guidelines in that they confront cost, a factor that physicians historically avoided; it was not considered ethical to do so. But with the rising costs of cancer care, and the out-of-pocket expenses patients face, doctors and health plans have little choice. The new term “financial toxicity” refers to the effect that these burdens have on patients, and their families, as they undergo treatment. Drs. Yu and Tischler agreed that oncologists had to be good stewards of this realm. “This is going to enhance the patient experience,” Dr. Tischler said. “We are really stewards not only of our individual patients, but of the population as well.”

Pathways seek to reduce the variability out of the system, not only to control cost, although that is a goal, but also to improve care by bringing more focus to evidence-based guidelines, panel members agreed. That said, pathway compliance will never be 100 percent, nor should it be; each patient is different, and clinicians must be free to tailor treatment toward individual needs and responses to treatment. Speakers agreed compliance would end up at approximately 80 percent.

Dr. Yu called for improvements in technology, and better integration of electronic health records with pathways, which he said would allow oncologists to record why they deviate from pathways. This could lead to more frequent updates and improvements in care.

What will make pathways successful? Payer and provider representatives on the panel agreed that “buy in” from treating clinicians was crucial. “You have to have people believe that it’s a transparent process of pathway development, that they respect and feel they had a voice in,” Dr. Yu said. Whether institutions use pathways developed by an outside vendor or build them in-house, it’s essential to have representation from “across the spectrum of academic and community medicine” of care, he said. “That helps build trust into the decisions,” he said.

Dr. Malin said WellPoint considered using an outside vendor for its pathways but ended up using in-house expertise, made up of oncologists and pharmacists, who developed the protocols in a process not unlike that used to place therapies on a formulary. Internal teams of oncologists and pharmacists put together summaries based on efficacy, quality of life, and cost. The external advisory group members came from community and academic oncology practices, including National Cancer Institute-designated institutions, she said.

The essential element of WellPoint’s program is that it offers rewards, not penalties, Dr. Malin said. If providers deviate from the pathway, which is anticipated, “they will still get reimbursed,” she said.

What about the most expensive drugs? Dr. Malin said that while WellPoint’s pathways plan aims to bend the cost curve, it will not keep cutting-edge therapies away from patients if the evidence shows they save lives.

“Our pathway is about rewarding quality care,” she said. “We’re not going to exclude something from the pathway simply because it’s more costly. Pathways, like the rest of clinical medicine, is an itirerative process … A groundbreaking therapy that is going to change the care for a large percentage of patients with a particular tumor type -- that would need to be put in the pathway right away.” By contrast, a therapy that would only affect a small share of patients would be added more slowly; for other therapies, as evidence accumulates, a therapy may have better or worse toxicity or effectiveness, and thus may be added or dropped, Dr. Malin said.

Dr. Yu emphasized that pathways must be dynamic, living vehicles that are constantly revised to include new findings. This is where better integration with technology will be critical, he said: if a regimen that was well-followed suddenly falls out of compliance, that would be an indication that there’s a new study, which should be reflected in a pathway update.

As Dr. Nabhan noted, “We don’t have a metric to decide, ‘What is the cost of one life saved for how long?’ we really don’t—that is the elephant in the room. … It’s critical to address at some point.”

About the Journal

The American Journal of Managed Care, now in its 20th year of publication, is the leading peer-reviewed journal dedicated to issues in managed care. In December 2013, AJMC launched The American Journal of Accountable Care, which publishes research and commentary devoted to understanding changes to the healthcare system due to the 2010 Affordable Care Act. AJMC’s news publications, the Evidence-Based series, bring together stakeholder views from payers, providers, policymakers and pharmaceutical leaders in the areas of oncology, diabetes management, respiratory care, and immunology and infectious disease.

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