How Minnesota Oncology Mitigates Oncology Pathway Burnout

Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC, director of pharmacy services at Minnesota Oncology, spoke with Evidence-Based Oncology (EBO) to elaborate on points covered during the panel discussion “Can Clinical Pathways Have Burnout, Too?” presented at Patient-Centered Oncology Care 2023, which The American Journal of Managed Care presented in Nashville, Tennessee, on November 7 and 8, 2023.

This interview has been lightly edited for clarity.

EBO: How can clinical pathways lead to added stress and burnout? Have you seen this in your own practice?

Hanna: Pathway burnouts have been things that we’ve started to see more and more in clinical practice across various institutions and practices. I think there’s a lot of opportunity for improvement. Pathways are certainly nothing new, but what we learned from our panel discussion is that we have seen the intent of pathways really transition over the years. Pathways were initially aimed to really identify optimal treatment strategies [and] optimal treatment modalities. Now, given the complex state of oncology, there are limitations within pathways coming from payers, there are limitations in pathway implementation and adoption coming from health systems [and] third-party vendors that may be regulating pathways, and it’s really posed a lot of challenges.

When you look at pathways, they don’t really take into account social determinants of health [or] value-based care delivery modalities; these were points that we were able to delve into during the panel. Within pathways, I think there’s a lot of opportunity and room for improvement in the grand scheme of things.

EBO: Is there anything specific that you’re doing at Minnesota Oncology to prevent this pathway burnout?

Hanna: If you’re familiar with Minnesota Oncology, we’re under The US Oncology Network, so we’re part of a pretty large network of practices.¹ This has allowed us to implement pathways that govern this network practice. We have a robust group that evaluates disease states [and] makes decisions in terms of pathway implementation based on clinical data and clinical updates—what’s coming out of the American Society of Clinical Oncology, the European Society for Medical Oncology [ESMO], and the American Society of Hematology, etc—and provide timely updates within pathways in most regards, especially when it comes down to things that may be paradigm shifting or practice changing.

One unique thing that we have done at Minnesota Oncology is that we have actually partnered with a local payer, Blue Cross and Blue Shield of Minnesota, and we have actually been able to demonstrate that utilization of the pathways has really been able to decrease total cost of care while not taking away from the safety and efficacy of the majority of the regimens that we’re utilizing. And we are in a contractual agreement with Blue Cross and Blue Shield of Minnesota, where we have things like gold carding access and gold carding privileges.² It’s really streamlined our workflows, it’s taken off a lot of staff and administrative burdens, and it’s something very unique, I would say, to Minnesota that many are not seeing across the country. And actually, a lot of people have come to us and asked about what we’re doing or what the structure really looks like.

Now, it took a lot of relationship building and trust between the payer and the health system, and I think that’s a very important thing to highlight. There’s oftentimes this negative connotation around payers, but if you can get in the same room, argue it out, [you can] develop certain strategies that are going to be mutually beneficial—because in the grand scheme of things, the patient should be the center of any conversation [including] what you adopt in pathways and what you develop with payers. By doing so, we’ve built this relationship. Now, again, tied to it, there are umbrellas of risk. If we don’t adhere to pathways to a certain threshold or if we don’t adopt certain degrees of biosimilars and such, we are at risk to some extent. But then at the same time, we get that benefit from adopting what we have in relationship with them.

EBO: During the panel, you talked about having one of the best integrated pathways in electronic medical records (EMRs) at Minnesota Oncology and mentioned how not all recommendations fit certain pathways. Can you elaborate on this?

Hanna: When you look at physician burnout that ties to pathways, in my opinion, I really think it has to do with how that pathway is integrated within the EMR, how quickly that pathway is updated, and [whether] it really provides value back to that physician. When you look at the things that we face on a day in and day out basis—staffing shortages, drug shortages, administrative burdens with everything else going on in the clinics—I think providers really want the most streamlined approach, especially when it comes down to pathways. I have dealt with multiple EMRs, multiple pathway rollouts, and multiple different ways of how pathways have been integrated. I would say having that seamless integration where a provider can answer a couple of questions that might dictate a certain regimen or certain product in terms of what’s recommended for the patient, it automatically ties to a treatment plan or a treatment regimen vs the physician having to exit the pathway or leverage another portal, then pick their regimens and their treatment plans. That has really allowed adoption of pathways, and also the quick adoption of novel approaches.

One great example we mentioned in our panel, if you look at the data that came out of ESMO [around the] EV-302 bladder cancer regimen [enfortumab vedotin in combination with pembrolizumab.] It was absolutely practice changing in this population³ that really hasn’t had a change in standard of care in decades. Which pathway has that implemented yet? Pretty much across the country, there may not be any pathway that has this specific regimen as a preferred option. We do anticipate approvals, we do anticipate National Comprehensive Cancer Network (NCCN) incorporation, and we do anticipate a publication, but just from the abstract and what was presented at ESMO, there was a standing ovation based on the findings of the study. How do you implement something like that quickly into a pathway where you’re not waiting on NCCN and your FDA approvals and such? Again, there’s also the opposite side to it where, even if you do have it within pathway and it is preferred, you might have payer limitations because the payer is still waiting for the approval and the data and such. So that’s also where it ties back to that point where this relationship between the payer and the health system can really help navigate and streamline some of these things.

References

1. Value pathways powered by NCCN—oncology clinical pathways. Accessed November 16, 2023. https://www.mckesson.com/Specialty/Oncology-Pathways/
2. Blue Cross and Blue Shield of Minnesota and Minnesota Oncology announce five-year collaboration. News release. Blue Cross and Blue Shield of Minnesota. August 22, 2019. Accessed November 16, 2023. https://bit.ly/3MMfMgm
3. Joszt L. First in decades: enfortumab vedotin + pembrolizumab beats chemo in first-line metastatic urothelial cancer. Am J Manag Care. Published online October 22, 2023. Accessed November 16, 2023. https://bit.ly/47jOmqm