Although payer management of oncology has come a long way from the “hands off” policies of just 5 or 6 years ago, clinical pathway programs are still in their infancy. Nonetheless, these programs are evolving as a primary means by which payers intend to control drug utilization in cancer treatment.
Payer Use of Oncology Pathways
Recent research conducted by HRA–Healthcare Research & Analytics, a market research consultancy based in Parsippany, NJ, reveals that clinical pathway programs have been initiated mostly by larger payers in the United States, with midsized and smaller organizations still working to define and implement pathways. Twenty-eight percent of the 47 unique managed care organizations (MCOs) participating in the research, covering more than 75 million commercial lives collectively, claim to have initiated a clinical pathways program, with the majority of the remaining plans (51%) highly engaged and interested in creating them (Figure 1
Figure 1. Payer Use of Clinical Treatment Pathways for Oncology
• Clinical pathways for oncology, while not yet widespread, are expected to take hold among a majority of participating MCOs in the immediate future – impacting over 100 million commercial lives.
Utilization of Clinical Treatment Pathways
- Percentage of Payers -
MCO indicates managed care organization.
“We’ve seen increased member responsibility through a fourth tier with coinsurance. Going forward, I see potential for a 5-tiered structure with preferred agents in a limited number of areas,” stated a key opinion leader participating in HRA’s research, commenting on changes to oncology management. “The largest thing will be more incentives to oncologists for following pathways—bonuses for following pathways, global budgets for common tumor types. But, it’s unlikely plans will have proscriptive management based on creating step therapies or a preferred formulary; instead, they’ll give financial incentives for the oncologists to help control costs by following guideline-based care.”
Perceptions of Payer-Initiated Pathways
HRA’s study, Changing Paradigms in Managed Care— Oncology Management
, adopted a cross-stakeholder approach to assessing changes to oncology management, including payers as well as healthcare professionals. Surveyed medical oncologists expressed a lukewarm response to the presence of payer-initiated pathway programs. Sixty-one percent of oncologists were either neutral or only mildly positive regarding the practice of payer establishment/promotion of pathway programs (Figure 2
). A notable minority were opposed to the practice.
Figure 2. Perceptions of Managed Care Payer Establishment/Promotion of Clinical Pathways for Oncologic Therapy
MCO indicates managed care organization.
“[Payers make it] very difficult to do any type of imaging studies needed to stage patients, and when you do treatments [payers] want patients to undergo basically a cookbook form of interventions, not focusing on individuals as much as they are algorithms,” stated one oncologist participating in the research. “So, they’re very algorithm- or protocol-driven as opposed to looking at the individual patient…you’re starting to take the decision- making away from the physician and giving it to someone that doesn’t know the patient.”
In fact, just 25% of the surveyed oncologists are working with payers on pathway programs, although an equal proportion of them are planning to do so in the near future (Figure 3
Even among payer organizations that have established clinical pathway programs in oncology, the primary source of these programs has been the National Comprehensive Cancer Network guidelines, which the majority of surveyed oncologists claim to be following as a matter of practice. HRA’s research does not portend any major changes to this approach in the near term, although some oncologists have hinted at major plans approaching them for input toward the development of more customized guidelines.
“In oncology…the guidelines, pathways, are not specific enough,” a key opinion leader participating in HRA’s research said. “All products are there, although some are second or third line.”
Figure 3. Oncologist Plans to Work With Payers on Clinical Pathways
• One-fourth of surveyed oncologists are currently working with payers on their clinical pathways programs, and among the balance, just about half plan to. Collectively, this brings the possible future potential up to more than half of medical oncologists.
• While large practices have been more frequently approached, oncologists from smaller and midsized practices are particularly interested in pursuing pathways programs with payers.