How Payers and Oncologists Really Feel About Clinical Pathways

Figure 1. Cancer Is Payers’ Number 1 Management Priority

Average Payer Score

To what degree is each of the following categories an overarching management priority?

According to the Managed Care Benefit Design Index, Fall 2011 (a survey of payers, N = 101), cancer topped the list of payers’ management priorities for the first time.

Source: Reprinted with permission from The Zitter Group. Managed Care Benefit Design Index. Fall 2011.

According to the 2011 Managed Care Benefit Design Index, cancer was the top-ranked management priority among payers (Figure 1). Mark Zitter, CEO, The Zitter Group, explained the reason for their concern: “Typically it is often cost-related and challenge-of-management-related, so this is clearly an issue for payers.”

To keep abreast of practice and management trends in oncology, The Zitter Group issues the Managed Care Oncology Index (MCOI), the results of a semiannual survey of 100 payers, 100 oncologists, and 100 oncology practice managers.

During a session titled Oncology Pathway Development and Implications for Managed Care at the 2012 Academy of Managed Care Pharmacy Annual Meeting, Zitter presented 2011 MCOI data and reviewed the rationale underlying clinical pathway use, current utilization trends, perspectives on pathway use, and implications for managed care pharmacy.

Survey respondents estimated that 16% to 23% excess cost can be eliminated from cancer treatment without adversely affecting quality of care or health outcomes. The cause of excess spending most commonly cited by payers and oncologists was excessive end-of-life treatment (35% payers, 30% oncologists). Other contributors to wasteful spending include inappropriate drug use and diagnostic testing, suboptimal distribution of prescription drugs, and utilization management requirements.

Payers are employing a number of traditional benefit management approaches to control spending. Prior authorization is by far the most commonly employed strategy. In cancer care, payers use prior authorization as a way to ensure appropriate utilization. Ultimately, payers and doctors agree that it is the doctors who drive treatment decisions. Hence, it seems logical that doctors should drive cost reduction. That, explained Zitter, is where clinical pathways come into play.

Doctors don’t like the typical payer responses to increased oncology costs: reimbursement reductions, prior authorizations, and specialty pharmacy or other site-of-care mandates. Pathways offer a more palatable alternative toward reducing practice variation, improving outcomes, and reducing cost.

A pathway represents an evidence-based approach to care that focuses on a specific disease or patient group with a relatively predictable course. For each disease or patient group, the pathway specifies which interventions to perform and in which sequence to use them. Pathway generation and maintenance requires a process for evaluating therapies and clinical approaches.

Forty percent of the payers surveyed already had pathways in place and the majority of those who did not indicated that they were likely to implement clinical treatment pathways in the near future (within 18 months of survey). Breast, lung, and colorectal cancers were the tumor types most commonly covered by clinical pathways (Figure 2). Payers and oncologists were optimistic that cancer care guidelines will improve the quality of cancer care and reduce cancer costs.

Figure 2. Payers Have Adopted Pathways for the Most Common Cancer Types

Does your organization currently apply clinical treatment pathways to manage cancer therapies?

Among the 40% of payers who have adopted clinical oncology pathways, breast, lung, and colorectal cancer were the most commonly covered tumor types.

Source: Reprinted with permission from The Zitter Group. Managed Care Benefit Design Index. Winter 2012.

Pathways are typically developed by individual provider groups or national organizations (eg, National Comprehensive Cancer Network, American Society of Clinical Oncology), not by health plans. Nearly 80% of payers agreed that they would rather enforce externally produced cancer care guidelines than create and enforce internally created pathways. Indeed, nearly 70% of those who had already adopted clinical pathways indicated that a third party pathway organization was responsible for pathway management. Although managed care is not typically involved in pathway development, pharmacists can play a significant role in informing the development process by providing data, vetting the pathways, and assisting with pathway enforcement.

Several reasons were cited among those who had chosen not to adopt clinical pathways. The most common were that their organizations had not reached consensus on which pathways to develop and that the management techniques in place were considered effective. Interestingly, these were also the top two reasons cited by oncologists who were not planning to adopt clinical pathways in the next 2 years. Adoption of clinical pathways does not necessarily mean that traditional management approaches need to be abandoned. About half of the payers integrated treatment algorithms into their existing prior authorization process.

Ultimately, for clinical pathways to be effective, the oncologists have to be using them. With that in mind, health plans are devising a number of ways to incentivize pathway use. According to payers surveyed, higher drug reimbursements and reduced administrative requirements (eg, prior authorization) are the most frequently applied incentives for physicians who adhere to pathways. Less commonly used incentives are expedited utilization reviews and reimbursement processing, in-network requirements, and preferred provider status within network. According to the MCOI, getting doctors on pathway may not be too difficult. The oncologist respondents found pathways influential and were in favor of their use. Of 60 oncologists surveyed, just less than half said they plan on adopting pathways within the next 2 years.

Funding Source: None.

Author Disclosure: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.