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Several initiatives that have a dramatic impact on healthcare today were born during that timeâ€“managed care, transitioning away from inpatient care toward outpatient care, and the introduction of clinical pathways.
Marcus Neubauer, MD
Think back to what healthcare was like in the early 1980s. Thirty years ago, electronic health records and oral chemotherapy were hardly blips on the radar, and vertical integration was in its infancy. Even though the healthcare environment was very different, many of the challenges we face today are the same. Rising costs, an aging population, and higher rates of chronic disease were issues back then for private and government payers, providers and patients, just as they are now. Several initiatives that have a dramatic impact on healthcare today were born during that time—managed care, transitioning away from inpatient care toward outpatient care, and the introduction of clinical pathways.
Originally, pathways focused on standardizing care as a way of managing the quality of care provided. The goal was to reduce unnecessary variability in clinical practice and improve outcomes. Evidence-based guidelines were developed and adopted throughout healthcare from general practice to specialties—including oncology. Over the years, the role of pathways has evolved and expanded significantly. Today, they are not only effective tools for improving the quality of care, but also for driving value in healthcare.The idea of driving value with pathways has gained the attention of payers, providers, and many thought leaders in cancer care. Treatment of cancer, in particular, has been identified as one of the fastest-rising cost centers in healthcare and has come under scrutiny for high drug costs, high rates of hospitalizations, and potentially unnecessary and expensive end-of-life care. Several studies from McKesson Specialty Health and The US Oncology Network reported over the last decade support for the use of evidence- based guidelines, specifically Level I Pathways, as an effective method of lowering cost while still demonstrating outcomes similar to those in the published literature. Level I Pathways, which were developed nearly 10 years ago by The US Oncology Network, are now refined into Value Pathways powered by the National Comprehensive Cancer Network (NCCN)—the result of the recent collaboration between the NCCN, McKesson Specialty Health, and The US Oncology Network.
A study conducted by The US Oncology Network and Milliman compared patients with colon cancer whose care followed physiciandeveloped Level I Pathways (also known as “on-pathway”) with other patients (“off-pathway”). The study found mean per patient cost differences of more than 30 percent (favoring the on-pathway group).1
Another study looked at patients with non-small cell lung cancer (NSCLC) treated in the community outpatient setting. Cost of care over a 12-month period and overall survival were compared between patients treated on-pathway versus off-pathway, and the study found overall outpatient costs to be 35 percent lower for on-pathway versus off-pathway choices (average 12-month cost, $18,042 vs $27,737, respectively) with no difference in overall survival observed.2 Results of both of these studies suggest that treating patients according to clinical pathways is a cost-effective strategy for delivering care, and highlights opportunities for oncologists to help rein in cancer care costs.Pathways help reduce costs by standardizing care. One of the biggest cost drivers in healthcare is high variability in care. This is especially true in the treatment of cancer, given the high and variable costs of oncology drugs. Following pathways leads oncologists down a path that ultimately results in a treatment option that has been proved the most clinically effective and cost-effective option. Pathways were developed with clinical efficacy, toxicity, and cost taken into consideration. In other words, when developing a pathway to treat a specific type of cancer, if 2 drugs offer the same efficacy and toxicity, the lower-cost drug, often a generic drug, is selected as the pathway treatment option. This also improves the predictability of cost for payers and patients.
Value Pathways powered by NCCN are an example of pathways that follow this formula. They are up-to-date, peer-reviewed, evidence-based practice algorithms for cancer treatment, and are designed to maximize survival, minimize toxicity, and provide cost-saving opportunities.3 They represent the same rigor that we put into creating and maintaining Level I Pathways over a decade ago, but now have the expert contribution of NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) panel members. Value Pathways powered by NCCN differ from NCCN Guidelines. They are a subset of NCCN Guidelines that take not only efficacy, but toxicity and cost into consideration to come up with a more succinct list of treatment choices that drive value. Currently, Value Pathways for chemotherapy decision making have been developed for more than 12 different diseases, and Value Pathways for radiation therapy are on the horizon.
To bring Value Pathways powered by NCCN and NCCN Guidelines to the point of care, McKesson Specialty Health offers Clear Value Plus, a regimen support tool that provides Value Pathways and NCCN Guideline choices at the point of care. Clear Value Plus also allows a provider to see the relative costs of selected regimens to help patients make informed decisions that take both efficacy and cost to patient into consideration. Clear Value Plus can be used as a stand-alone Web-based tool, integrated in the physician workflow through clinical interfaces with multiple electronic medical records (EMRs), or fully embedded with McKesson Specialty Health’s iKnowMed Generation.2 In all instances, Clear Value Plus delivers clinical and financial transparency along with real-time reporting.Some wonder if pathways are here for the duration or if the introduction of personalized medicine will eliminate the need for standardized care. On the surface, the idea of individualized care determined by genetic testing might suggest pathways will be rendered obsolete. However, Value Pathways take into account the cancer causing mutations that require specific treatment choices. So, if anything, the progression toward individualized medicine will actually lead to more refined pathways and ultimately better outcomes as the most effective treatments are used.
Likewise, questions arise about the effects of different payment scenarios using pathways. Payers are exploring a myriad of payment options to address spiraling costs, including bundled payments for treatment. Pathways inherently make cost of treatment for different types of cancer more predictable and can be a great tool in helping physicians and payers estimate costs and negotiate appropriate bundled payments.
Thus far, practices using Clear Value Plus are giving very positive feedback. Users like having access to Value Pathways powered by NCCN, NCCN Guidelines, and financial information, all at the point of care. Also, because treatment decisions are recorded in Clear Value Plus, participating practices can use reports for quality improvement and payer contracting around value-based initiatives. Oncologists understand that when patients receive standardized care anchored in clinical quality and evidence-based medicine, the opportunity for positive outcomes increases, and oncologists can help keep costs in check. With this in mind, pathways will likely be an integral part of oncology care delivery for the foreseeable future.