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Oncologists are all faced with the same challenge-delivering the best cancer care possible while reining in rising costs and one answer that many oncologists are looking at is cancer management systems.
Whether they are a part of a large cancer center in a metropolitan hospital or a small three-person practice in Montana, oncologists are all faced with the same challenge—delivering the best cancer care possible while reining in rising costs. One answer that many oncologists are looking at: cancer management systems.
Cancer management systems go well beyond the electronic medical record (EMR), and are designed to maintain clinical quality while reducing costs. Many entities, including insurance companies, hospitals, oncology networks, and some oncology practices, are developing and/or using these models, which come in a variety of formats, including computer software and Web-based programs. The systems sometimes focus on one area, such as prescribed drugs, or provide guidance on all aspects of treatment via clinical pathways.
By decreasing variability and increasing predictability, cancer management systems aim to provide consistent patient outcomes and decrease overall costs of care, not necessarily by choosing the lowest cost therapies, but by decreasing interventions, such as emergency room visits.
“The challenge we face in health care in general, but in oncology in particular, is the rising costs of care,” said Kathy Lokay, chief executive officer of D3 Oncology Solutions, which offers the Via Oncology Pathways system to community and academic oncologists. “Payers are becoming aggressive in trying to get these costs under control.”
“Several factors affect the drive to create new approaches to manage the cost and delivery of cancer care, including an increase in the employee cost share, which is shifting demand for better care for the money; employer expectations that comparative effectiveness research be included in benefit design; and a variation in care by geographic location,” said Amy Schroeder, RPh, of DK Pierce & Associates, a strategic consulting firm specializing in reimbursement issues. “Therefore, all stakeholders in health care are looking for ways to objectively confirm that cancer patient care is the best value, based on clinical outcomes and cost to the health care system.”
However, many oncologists are unsure whether they should wait to see how or if reimbursement is restructured or whether they should embrace these programs now. “Taking a wait-and-see attitude might be a misstep,” said Schroeder, “because it might take the decision out of their hands.
“Make the decision that is best for their organization before someone makes it for them,” she said. “Eventually, some other entity—a hospital, accountable care organization, or payer—could implement a system that may not be the collaborative approach” that oncologists seek.
Many cancer management systems are based on clinical pathways. Although some physicians embrace these evidence-based treatment protocols, others derisively call them “cookbook” medicine, implying that pathways take the skill out of practicing medicine and remove the decisions about patient care from the doctor.
The clinical pathways that form the basis of cancer management systems are generally designed by a committee of doctors who, based on a review of all the evidence, formulate a treatment algorithm for patients with a particular type of cancer. The pathways committee considers three issues: efficacy, safety, and cost, with efficacy being the first and most important consideration.
Pathways are similar to treatment guidelines, and some doctors ask why bother with the expense of a pathways system when they can just read the guidelines. “The difference between guidelines and pathways is pretty dramatic,” said Lokay. “Guidelines do not try to drive care utilization. They tend to offer a multitude of choices for any patient, whereas a pathway says, ‘Among all those choices, can we all agree on a handful, which are really the best for these patients?’”
Most pathways are designed to fit about 80% of patients, and a doctor is always free to go off pathway for the exceptions, she added.
Lee N. Newcomer, MD,
“Pathways doctors make better doctors,” said Lee N. Newcomer, MD, senior vice president, Oncology, Women’s Health and Genetics for United Healthcare. “Pathways are about doing what the evidence says is best for that patient, but they are never 100%. There will be some patients that have a medical reason why they could not use the drugs in a pathway, and going off the pathway for them is always acceptable. There will always be a huge need for physician knowledge. So, this does not diminish the role of the physician at all.”
Instead, he said, pathways standardize treatment within a practice. For instance, “a pathways program helps the group select a regimen for a specific clinical condition. If you are in a large group practice, you could have several partners prescribing different regimens for the same type of patient. That causes confusion for the nursing staff and confusion for the staff handling the night calls. There is an advantage to becoming consistent in your approach as a medical practice. It reduces errors, and it helps with patient teaching because you are teaching the same thing.”
“Cancer management is not so much a technology as an approach to care,” said Kjel Johnson, PharmD, senior vice president of strategy and business development at ICORE Healthcare/Magellan Pharmacy Solutions, which offers a pharmacy management program to insurance companies. In the case of oncology, it behooves insurers to encourage chemotherapy in the physician’s office because it is more cost effective and the doctor controls the patient’s care. His program helps support that aim.
The challenge we face in health care in general, but in oncology in particular, is the rising costs of care.”
There are many advantages to having a cancer management system in place, according to the sources interviewed for this article. The staff benefits because they become very familiar with certain regimens. Patients benefit because they are receiving the highest available care.
The practice benefits in several ways. If a clinical pathways program is in place and the practice follows that program, it might receive an incentive from the payer, such as enhanced payments for evaluation and management, and shared savings. Cancer management systems can also help reduce variation in care, better control drug inventory, and document care to match clinical recommendations. Practices might be able to use these metrics when negotiating with payers.
Pathways may also help with the drug spend. If 80% of the breast cancer patients are receiving the same regimen, that increases the amount of any single drug that a practice buys, and being able to buy higher volumes might allow some pricing leverage when purchasing drugs.
However, Newcomer said that saving money is not necessarily the main focus of these systems. “If you are treating patients consistently, you can start measuring your performance. When every HER2-, ER-positive breast cancer patient is being treated with the same regimen, then you start to have predictability about how much it is going to cost to treat that patient. You start to see fewer errors and complications because everyone is familiar with that one regimen,” Newcomer said. That information makes the practice more attractive to a hospital if the practice wants to merge, or to an accountable care organization that is looking for a cancer center to refer patients.
United Healthcare is piloting a program with six community oncology practices to measure performance with pathways. Right now, practices that use pathways systems can measure whether doctors are following the pathway, but they don’t normally track complication rates, emergency room rates, and other costs.
The six oncology practices either purchased a program or developed their own program; United Healthcare did not tell them which program to use. United Healthcare will gather information about the results of following the program in the hope of gaining a better understanding of how patients are responding to the pathways, and which pathways are the best practice.
“Custom designing care for a lot of oncology doesn’t make sense to me because there is good evidence about what works and what doesn’t,” said Newcomer. “To ignore that evidence I think is not particularly good patient care. I always struggle with why someone would not want to use the best evidence when it tells us how to provide the best care.”