How Payers and Oncologists Really Feel About Clinical Pathways

Kim Farina, PhD
Published: Tuesday, Nov 06, 2012

Figure 1. Cancer Is Payers’ Number 1 Management Priority

To what degree is each of the following categories an overarching management priority? Cancer Is Payers’ Number 1 Management Priority
Average Payer Score

According to the Managed Care Benefit Design Index, Fall 2011 (a survey of payers, N = 101), cancer topped the list of payers’ management priorities for the first time.
Source: Reprinted with permission from The Zitter Group. Managed Care Benefit Design Index. Fall 2011.

According to the 2011 Managed Care Benefit Design Index, cancer was the top-ranked management priority among payers (Figure 1). Mark Zitter, CEO, The Zitter Group, explained the reason for their concern: “Typically it is often cost-related and challenge-of-management-related, so this is clearly an issue for payers.”

To keep abreast of practice and management trends in oncology, The Zitter Group issues the Managed Care Oncology Index (MCOI), the results of a semiannual survey of 100 payers, 100 oncologists, and 100 oncology practice managers.

During a session titled Oncology Pathway Development and Implications for Managed Care at the 2012 Academy of Managed Care Pharmacy Annual Meeting, Zitter presented 2011 MCOI data and reviewed the rationale underlying clinical pathway use, current utilization trends, perspectives on pathway use, and implications for managed care pharmacy.

Survey respondents estimated that 16% to 23% excess cost can be eliminated from cancer treatment without adversely affecting quality of care or health outcomes. The cause of excess spending most commonly cited by payers and oncologists was excessive end-of-life treatment (35% payers, 30% oncologists). Other contributors to wasteful spending include inappropriate drug use and diagnostic testing, suboptimal distribution of prescription drugs, and utilization management requirements.

Payers are employing a number of traditional benefit management approaches to control spending. Prior authorization is by far the most commonly employed strategy. In cancer care, payers use prior authorization as a way to ensure appropriate utilization. Ultimately, payers and doctors agree that it is the doctors who drive treatment decisions. Hence, it seems logical that doctors should drive cost reduction. That, explained Zitter, is where clinical pathways come into play.

Doctors don’t like the typical payer responses to increased oncology costs: reimbursement reductions, prior authorizations, and specialty pharmacy or other site-of-care mandates. Pathways offer a more palatable alternative toward reducing practice variation, improving outcomes, and reducing cost.

A pathway represents an evidence-based approach to care that focuses on a specific disease or patient group with a relatively predictable course. For each disease or patient group, the pathway specifies which interventions to perform and in which sequence to use them. Pathway generation and maintenance requires a process for evaluating therapies and clinical approaches.

Forty percent of the payers surveyed already had pathways in place and the majority of those who did not indicated that they were likely to implement clinical treatment pathways in the near future (within 18 months of survey). Breast, lung, and colorectal cancers were the tumor types most commonly covered by clinical pathways (Figure 2). Payers and oncologists were optimistic that cancer care guidelines will improve the quality of cancer care and reduce cancer costs.

Figure 2. Payers Have Adopted Pathways for the Most Common Cancer Types

Does your organization currently apply clinical treatment pathways to manage cancer therapies? Payers Have Adopted Pathways for the Most Common Cancer Types

Among the 40% of payers who have adopted clinical oncology pathways, breast, lung, and colorectal cancer were the most commonly covered tumor types.
Source: Reprinted with permission from The Zitter Group. Managed Care Benefit Design Index. Winter 2012.

Pathways are typically developed by individual provider groups or national organizations (eg, National Comprehensive Cancer Network, American Society of Clinical Oncology), not by health plans. Nearly 80% of payers agreed that they would rather enforce externally produced cancer care guidelines than create and enforce internally created pathways. Indeed, nearly 70% of those who had already adopted clinical pathways indicated that a third party pathway organization was responsible for pathway management. Although managed care is not typically involved in pathway development, pharmacists can play a significant role in informing the development process by providing data, vetting the pathways, and assisting with pathway enforcement.

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Community Practice Connections™: 18th Annual International Lung Cancer Congress®Oct 31, 20181.5
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