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Clinical pathway programs are evolving as a primary means by which payers intend to control drug utilization in cancer treatment.
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.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).
• 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.
MCO indicates managed care organization.
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.”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.“[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.
• 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.
“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.”
Payers engaged in clinical pathway programs primarily intend to financially reward oncologists for adherence to the pathways through pay-for-performance incentives (Figure 4). A minority expect simply to continue the practice of recommending that oncologists follow guidelines, without implementing any penalties or rewards for compliance; and a few organizations adopt the very punitive approach of preventing oncologists who do not adhere to the guidelines from network participation in their plans.
• The most common requirement concerning clinical pathways—especially in the future—is/will be to give physicians an incentive to follow the pathway, although a subset of payers expect that simple “encouragement“ (rather than incentives) will be the norm.
Changes to oncology overall—highly expensive new treatments, targeted therapies, increased survivorship, and the decline of the “independent” practitioner—have created the perfect storm for greater payer control of a traditionally “hands-off” category.
Proponents of pathway programs tout their benefits in promoting appropriate use of medications—and in some cases, controlling costs. As one payer executive in the HRA study states, “…At the end of the day, [payers]…have to figure out what we can pay for. Our system is unsustainable and needs to base care on real, evidence-based choices. It will become very important to show our choices make sense, especially if we have many possible pathways.”
Opponents view pathways as limiting physician choices in patient care, inserting standardization of care when, in many cases, exceptions should apply.
“Some MCOs adopt [clinical pathways] because it’s ‘the right thing to do’ (the stated reason), and it helps keep a lid on costs (the unstated reason),” a payer executive participating in the HRA research said. “Guidelines are neat but not always correct, such as HRT [hormone replacement therapy]. I’m not sure if the practice will continue to grow, or where it will go if it does.”
Oncologists and oncology nurse navigators participating in HRA’s research both agree that payers have become far more active in their management of oncology over the past few years—a trend that is expected to continue. A majority of healthcare practitioners in the research remain vehemently opposed to payer involvement in prescribing decisions. Transferring prescribing “control” from the physicians to payers, an expectation of denials for coverage, and more sophistication and complexity in payer management tools all are cited as reasons to oppose payer involvement.
“When payment gets increasingly tight, the payers clamp down on care, and as Medicare denies more care, insurers will follow suit,” an oncologist participating in the research said.
Nonetheless, despite the opposition, some oncologists do see value in the exertion of greater payer control on oncology. Those who are more amenable to payer interventions claim that guideline-based care will lead to better, consistent care with less waste overall. The continued evolution of targeted therapy, and the prospect of payers funding testing for the appropriate biomarkers, also is noted on the positive side. And, there is some perception that guideline-directed care will help educate insurers on best practices in cancer care.
“More constructive control…” is how one oncologist describes increased payer management of the category. “Oncology is now becoming an expensive part of our healthcare system. Drugs are more and more expensive and patients are living longer; testing is more complex and expensive from the molecular level to the gross diagnostic testing level, such as x-rays.”
Another oncologist states that tighter payer controls “will establish [the] best pattern of care and dictate choice of [treatment].”
Regardless of opinion or position—across payers or providers—oncology is now a “managed” category. The question remains, however, will payers and providers be able to come together to design and implement appropriate management strategies that save costs while still providing the best in patient care? Only time will tell.