A divide has developed between pathways that primarily serve physicians and those that cater to payers that are trying to rein in costs.
Clinical pathways were originally created to standardize cancer care and ensure patients receive the best evidence-based treatment for their disease. A divide has developed, however, between pathways that primarily serve physicians and those that cater to payers that are trying to rein in costs. Among those on the side of physicians and practices is Via Oncology, a Pittsburgh-based pathway development company whose pathways emphasize drug efficacy and toxicity rather than price, said Gordon Kuntz, Via’s senior director of strategy.
In theory, oncology pathways always consider efficacy first in guiding a drug choice, followed by toxicity. Cost is only to be used as a kind of tie-breaker between 2 or more similarly effective treatments. But some payers require doctors to use pathways that put more weight on cost or that steer them toward certain less expensive drugs and make it difficult to go off-pathway when needed.
When doctors in Via’s network create pathways, they are aware of drug costs, but Kuntz said those prices rarely contribute to their decisions. “About 5% of the time, we actually look at cost as a driver. Some payers want cost to be a more important factor, and that’s not how we operate,” he said at the World Congress 4th Annual Oncology Market Access Summit in March. Kuntz said his company has passed on opportunities to do business with payers because of their greater focus on cost. “Because it’s our philosophy—it’s in our DNA—it would be just wrong for us to develop a specific pathway for a payer,” he said.
Practices become paying members of Via’s network because they want to improve their patient outcomes through standardization of treatment, Kuntz said. Pathway programs also provide data that demonstrate a practice’s value by showing how physicians made treatment choices, he said.
This can help attract referrals, which is important for community practices and academic centers that are not part of large hospital systems. Pathways can make it easier to participate in new payment models, such as medical homes. For large practice networks, pathways can help ensure consistency of quality across many locations, he said.
Via originated at the University of Pittsburgh Medical Center and was spun off as a company in 2009. The number of physicians in its network of clients is approaching 1500 at 38 providers, including 10 academic centers, 13 hospitals, and 15 community-based practices in 27 states, Kuntz said. The clinical pathways are developed by 31 disease committees made up of physicians in the network. Most of the committees meet quarterly to review the latest research and update drug recommendations; after a meeting, it takes 4 to 6 weeks for the company to integrate any pathway changes into its software.
Unlike some other companies, Via always has a single best drug option at the end of each pathway, although it also provides an alternative treatment plan for patients who have neuropathy, in case of a drug shortage, or for other special situations, Kuntz said. As is standard in the industry, 80% of patients are expected to be treated on pathway, a quarter of whom may be assigned to the alternative scenario. Up to 20% may be off-pathway, with physicians required to explain their reasoning through Via’s software.
Kuntz said Via is unique in that it supports all 3 major oncological treatment approaches. Its pathways cover 95% of its members’ medical and radiation oncology cases and about 60% of surgical oncology. However, as with other companies, individual pathways do not integrate the 3 methods. “Today, they live a little bit independently,” he said. “We’ve talked about, how do we create a true multidisciplinary scenario?”
Part of Via’s mission is to promote clinical trials. With its pathways software, a physician enters a patient’s data and proceeds to a recommendation page that first presents relevant trials available at that practice. “The physician can’t get past that, to the standard of care, without saying either, ‘Yes, please screen this patient for trials’ or ‘No, the patient doesn’t want to be on a trial’ or ‘No, I don’t think this trial is applicable to this patient.’ And you have to say why,” Kuntz said. Patients aren’t automatically enrolled in trials, but the system can send an e-mail to a trial screener who can quickly meet with the patient. Adopting the software has helped practices increase their clinical trial accrual rates, he said.
Via’s competitors include McKesson Specialty Heath/US Oncology Network, which also sells clinical pathways to practices. Payer-side pathway developers include Cardinal Health, eviCore, Eviti, New Century Health, and Anthem’s AIM Specialty Health. Kuntz said the companies differ in the ways they develop their pathways, how transparent their processes are, the number of diseases they cover, the pathways’ levels of detail, how well they support practices, and the number of choices at the end of each pathway.
Kuntz said he knows of a few practices that are large enough to develop their own pathways, such as Moffitt Cancer Center in Tampa, Florida, but he cautioned that the work “is not for the faint of heart.” “While the building (of pathways) is very, very challenging, the maintenance is worse,” he said. “We have 1 very large practice that uses our software to develop their own pathways, and frankly, it’s been very challenging.” Although Via does not sell pathways to payers, it does regularly work with them. Aetna and some Blue Cross Blue Shield plans allow physicians to use clinical pathways from multiple developers, and Kuntz said his work involves facilitating those kinds of relationships. “Our job is to be transparent with payers, to show them what we do and how we do it, so that they can get comfortable with the pathways that our clients are using,” he said.
In theory, clinical pathways software also enables automation of the prior authorization process, providing practices with much-desired relief from an onerous and expensive administrative burden. But Kuntz said getting payers to accept authorization requests electronically has proved challenging. “That’s incredibly difficult. Prior authorizations have resisted automation forever.” Via already collects the data needed for prior authorization, such as disease stage and biomarkers, but only a small fraction of payers are set up to accept the information through e-mail or a digital feed, rather than fax or phone, he added.
Increased coordination with payers will be part of the future of pathways, Kuntz said. For example, insurance claims data can be combined with patient data to guide the development of payment bundles for accountable care organizations. Pathways will also continue to expand to cover the full continuum of care, he predicted, noting that Via’s software has features related to diagnostic workup, discontinuation of therapy, hospice, and survivorship. He said the company also recently launched Via Triage, which guides nurses as they handle patient phone calls and respond to adverse events of drugs.
Other changes that will affect clinical pathways in the coming years include the arrival of personalized medicine, which will have to be handled differently than standard chemotherapy, and the development of pathway certification programs by ASCO and potentially other organizations, Kuntz said. He said Via is in “pretty good shape” to satisfy the criteria ASCO is developing, although meeting the organization’s call for patient input as part of pathway decision making is a challenge.
An audience member asked Kuntz about the prospect of building clinical pathways that further promote value-based care by considering the total cost of care. Kuntz said Via’s physician committees consider toxicity when building pathways, but not at the level of empirical, numerical detail the questioner suggested.