Experts Discuss the Place of Pathways in Oncology Payment Reform

At the 2015 Community Oncology Conference, payment reform was all around—the theme for the meeting this year was in synch with what the rest of the healthcare world is grappling with: Community Oncology 2.0, Moving Forward on Payment Reform.

A late afternoon session on the first day of the meeting was the panel discussion, “The Pathway Conundrum: How Many Do We Need and How Restrictive?” Participants in this panel included Bruce J. Gould, MD, president and medical director of Northwest Georgia Oncology Centers and the current president of the Community Oncology Alliance; Ira Klein, MD, MBA, FACP, national medical director, Clinical Thought Leadership, Aetna, Inc; and Jennifer Malin, MD, medical director for Oncology Solutions and Innovation, Wellpoint.

Dr Malin informed the audience about several pilot models that are actively being evaluated, including Anthem’s payment reform model which is in its first phase with implementing pathways; Aetna has developed a distinct pathway program as well she said, and Dr. Barbara McAneny’s COME HOME model implements pathways that were developed in house.

When queried on the utility of clinical pathways, Dr Malin referenced several research studies that have evaluated pathways across several practices. “One such study by US Oncology, a pioneer in the field, found that adherence to pathways improved outcomes and successfully reduced costs,” she said.

Dr Klein agreed, adding, “If we want to convert from pay for volume to pay for value, pathways are important for that. The current pathway models are proof that evidence-based medicine does work and it is convincing enough to adhere to them.” Just going through the mechanistic elements of the workflow process in an office are a big help and pilots are definitely helpful to fix kinks in the model. In Dr Gould’s view, pathways are a milepost on the road of payment reform. “The model that will help us save costs will be the Oncology Medical Home (OMH) model, and adherence to guidelines will further contribute to the cost savings,” he stated.

Moving on to a discussion on narrow pathways and their utility with respect to cost of care, Dr Gould said that while some payers will agree with adherence to guidelines like those developed by the National Comprehensive Cancer Network (NCCN), narrow pathways are definitely more cost-saving. Providing OMH as an example, he said that while OMH follows NCCN guidelines, the question arises: how many pathways can be followed?

The panel was then asked to define the role of bundled payments in pathways.

Dr Malin responded that while there is still a bit of discrepancy in the understanding of a bundled payment, if a pathway could implement a true bundled payment, which includes services, cost of drug for a fixed period, the pilot models would gain an incredible experience from the resulting data.

“However, if you don’t have a measure to compare individuals within a particular group, then there’s a lack of management strategy. You need to use measures that could help understand who’s doing what within a practice. The discipline of using a pathways program helps promote supportive agents and improves efficacy of the entire system,” added Dr Klein. Dr Gould however warned that with reporting programs, there will be a burden of data collection necessary to ensure that patients are getting treated appropriately.

The panel was then asked to comment on how they respond to a practice that demonstrates savings with a different pathway than what the payer wants.

Dr Klein declared that Aetna used a clinical decision support company to develop their pathways program. “Several companies have done that exercise with us,” he added. “It was a matter of practicality of buying the pathways from the marketplace, as long as it aligned with [Aetna’s] policy objectives.”

Dr Gould said that his practice did go to [Aetna] with the OMH model and the pathways they had developed independently. “We used a third party intermediary to iron out the process,” he said.

Asked to comment on the influence of the NCCN and American Society for Clinical Oncology (ASCO) frameworks on payment reform, Dr Klein said that both models have merit. “But me, as a payer, I have to accept some parts of the proposition. We have claims systems, regulatory issues, shareholders, and other matters to consider in our business model. Some of the elements of these propositions do not align with our business goals.”

When asked whether pathways and personalized medicine clash, Dr Malin said that was an important question. While they follow NCCN guidelines for the most part, if there is no evidence reported, then the treatment will not find coverage in their pathways.

Dr Klein agreed, adding providers need to generate evidence for using specific drugs for a particular condition.