Health Plan Perspectives on Clinical Pathways

Michael Kolodziej, MD: Without a doubt, everyone who’s watching this knows that I’m a pathways guy and that I absolutely love clinical pathways. During my time at US Oncology, I was one of the founding fathers of clinical pathways. I believe they’re extremely valuable in helping physicians make value-based clinical decisions. So, yes, I believe pathways improve quality, reduce variability, and potentially have a positive impact on cost of care. I think pathway construction does require a certain amount of flexibility to account for patient variability; none of the pathways were ever designed to be for every single patient that walks in the door. There’s always the opportunity to identify when an alternative to the pathway choice is the right clinical alternative. I used to always tell my patients, “A good doctor knows when not to follow the pathway,” and that’s really true. I think for a large population, pathways offer the best available evidence. But there are always clinical exceptions to that rule.

There are many challenges associated with clinical pathways. So, I started working on them a decade ago, and we were clearly ahead of our time when we first built them. They have come into their own now. There are a number of challenges. I think physician adoption, acceptance, even support of the concept behind the use of clinical pathways is a process improvement to us, but a challenge from the very beginning. What makes you think you should tell me how to treat my patient? But that was never the intent.

I think as we go forward, and as we start thinking about alternative payment models and managing patients within the practice—the payer not being the entity that says no, but rather the practice having taken responsibility for that—pathways have become absolutely critical to understanding how patients are being managed and what the consequence of those decisions are. I think a big, big part of the challenge has been to get oncologists to get behind the approach. We still have some challenges. There are administrative challenges. There are multiple pathways out there. I have argued that they’re not all that different. But they do provide some administrative challenge to the practice. I think that challenge does have a relatively straightforward technological solution, and I anticipate that it’ll be solved fairly quickly.

The question of whether there’s a kind of doctor who likes pathways versus the kind of doctor who doesn’t like pathways is a complicated one, and I’m not sure I have the answer to that. What I do know is this: the treatment of cancer is remarkably regional and strongly influenced by where you trained and who your mentors in training were. And I’m not sure that’s a good thing, but it certainly is something that we have seen over and over again. You can look at, for example, the patterns of care regarding adjuvant management of breast cancer, and the East Coast and West Coast are different.

Pathways do have the opportunity to eliminate some of that variability that does not bring value. I’m an older practitioner, so I’ve had enough experience to know that the distinctions between some of these regimens are pretty small. The only thing I’ve observed over the years is that for the most part—and I think practitioners who have really thought about it find that the pathway selections are what they do most of the time anyway—it doesn’t require a lot of change in your pattern of practice.

I work[ed] for Aetna, and at Aetna, we [did] have a preferred pathways program. It’s being implemented in a geographic fashion because that reflects our market structure. And we expect every provider, every oncologist within a given geographic area, to participate in the pathway’s process. We do not mandate a certain degree of performance, but we do reward a higher percentage of aggregate performance. We do not adjudicate rewards based on an individual patient, and that’s a very important distinction. If you are in New York and you’re at an academic medical center in New York City, yes, we do expect you to use clinical pathways. And if you’re like my old community practice in Upstate New York, we expect you to use pathways, as well. So, the answer is yes, we expect all of our providers to participate in the program. Now, the truth of the matter is that some providers within our network have contracts that allow them to have an out. We can’t force everybody to do it, but our intention is to get as many as possible.