Clinical Pathways As Care Model

Bruce Feinberg, DO, initially participated in a program focused on standardizing care for cancer patients in 1994. As the founder of Georgia Cancer Specialists, a group of oncologists based in Atlanta, he implemented a system in which physicians in the group followed similar treatment options.

Through the years, Dr. Feinberg has heard of comparable efforts with different names such as disease management, clinical guidelines, care algorithms, or pathways. They all had the same goal: reducing the wide variation of care and high costs associated with oncology.

Dr. Feinberg still considers the concept a small industry, but it is becoming more common and is expected to grow in the coming years. He is now involved with a clinical pathways program that could be a model to follow for other healthcare professionals. Dr. Feinberg, chief medical officer and vice president of Cardinal Health Specialty Solutions, is working with CareFirst BlueCross BlueShield on a collaboration that has benefited providers, patients, and payers.

At the American Society of Clinical Oncology’s annual meeting in early June, the companies presented data that showed that the pathways program for breast, colon, and lung cancer saved approximately 15% on cancer-related claims costs and reduced the probability of an inpatient admission by 7%. At the same time, physicians have shared in the cost savings and received financial incentives for participating in the voluntary program.

An analysis was also published online in the Journal of Oncology Practice [doi: 10.1200/JOP.2012.000871]. Jim M. Koeller, RPh, MS, the study’s author and a professor of pharmacoeconomics at the University of Texas, received the database from CareFirst and performed an independent evaluation of 78,821 claims from 193 physicians at 46 sites representing 4173 patients. He concluded that the pathways saved $30.9 million for the health plan and $10.3 million for the participating sites: $7.0 million from drugs and $3.3 million from hospitalizations. To Dr. Koeller’s knowledge, the CareFirst-Cardinal Health program is the first multi-state, general pathways program that has proven to decrease costs.

“We were able to show that pathways save money, save hospitalizations, and it is a reasonable thing to do,” Dr. Koeller said in an interview with First Report Managed Care (FRMC). “Doctors seem to get through it. I am not sure they enjoy it, but it has been successful.”

Most hospitals have protocols for acute care conditions such as pneumonia and inner ear infections, in which doctors are required to follow the same routine. For chronic conditions such as cancer and rheumatology, though, pathways are a “whole new game,” according to Dr. Koeller, but he noted they are becoming more popular.

The US Oncology Network, supported by McKesson Specialty Health, and the National Comprehensive Cancer Network are partnering to develop clinical guidelines for 19 tumor types. Via Oncology, a subsidiary of the University of Pittsburgh Medical Center, has grown its pathways program from an institution dealing with a single type of cancer to covering >90% of cancer types. Eviti, Inc. has developed software for pathways through a collaboration of oncologists, actuaries, insurers, and software engineers. The company works with payers to develop the pathways rather than with providers.

Cardinal Health now has 12 pathways contracts with 10 insurers in 15 states and the District of Columbia. The company has started similar initiatives in rheumatology and urology. Dr. Feinberg said behavior modification differs depending on the disease state. In oncology, physicians typically believe giving patients 2 or 3 drugs may help more than a single drug even if the single drug is as effective and is less toxic. Meanwhile, in rheumatology, physicians often escalate the dosage of medications before they evaluate the effectiveness of the initial lower doses.

“[Pathways are] not going to go away,” Dr. Koeller said. “We have to get better control of how we manage cancer. Pathways are a reasonable and useable tool to do that…The systematic application of resources is what the intent is. That just needs to be done.”

The oncology partnership began 5 years ago soon after Winston Wong, PharmD, received a promotion at CareFirst. The insurer’s chief medical officer expanded Dr. Wong’s role from managing the prescription benefit to being in charge of all drug utilization within the plan, both in the prescription and medical benefit. After analyzing the spending on medications, Dr. Wong found that 35% to 40% of the costs were related to oncology. At the time, most of CareFirst’s competitors were dealing with the high costs by lowering physicians’ fee schedules.

However, Dr. Wong noticed that decreasing the fees created a rift between health plans and physicians. He also determined that physicians tended to prescribe more expensive drugs to compensate for the reduced payments, canceling any of the savings the health plan would see from decreasing reimbursements.

As he explored his options, Dr. Wong came across P4 Healthcare, a firm founded by Jeffrey Scott, MD, who was Dr. Feinberg’s first hire at Georgia Cancer Specialists. P4 had practice management software that monitored claims submitted to health plans. Dr. Wong and Dr. Scott discussed a collaboration between the companies, and in 2008, they began monitoring prescribing patterns and put together a treatment pathway.

Before launching the program, CareFirst and P4 knew they needed to work with physicians rather than creating an adversarial relationship. If physicians agreed to follow the pathways, they would receive incentives such as a signing bonus, an increase in reimbursement for evaluation and management service, an opportunity to share in the savings, or a combination of incentives. Cardinal Health acquired P4 in July 2010. Later that year, Dr. Feinberg left Georgia Cancer Specialists to lead Cardinal Health’s foray into pathways.

Neither Cardinal Health nor the payer that sponsors the program participates in the process of developing pathways. Physicians create pathways for the various diseases, although Dr. Feinberg noted the payers give physicians a “mission statement” of “better health through better healthcare at lower cost” and ask them to explain how they will implement the programs to reach their goals. If CareFirst created a pathway, Dr. Wong said it would be nearly identical to the ones developed by physicians, but he added that physicians are much more willing to participate if they have input.

“If you want to modify [physicians’] behavior, if you want to get everybody to come on board with this consensus and come to agreement, then you really have to engage them,” Dr. Feinberg said in an interview with FRMC. “You cannot just say to someone, ‘Here, do this.’ That is what we learned in our experience. That engagement piece is something we strongly believe in.”

To date, CareFirst has been pleased with the partnership with Cardinal Health, which is taking place in Maryland, Virginia, and the District of Columbia. After initially on breast, lung, and colon cancer, they have added lymphoma, myeloma, and prostate and ovarian cancer as well as rheumatology. With physicians agreeing to cost-effective prescribing patterns and complying with pathways, they have standardized care and lowered costs for CareFirst. The physicians are also able to benefit financially.

“I am happy with [the results],” Dr. Wong said in an interview with FRMC. “The question really comes out now is where do we go from here? That is the question we are still asking ourselves. It is nice that we can go and say the cost savings consistently went upwards, but it is like everything else. Once the physicians are in the practice pattern of maintaining some consistency, the cost savings pretty much plateau out. We need to figure out now what the next step is.”

One way of maintaining cost savings is by supporting community oncology practices, which are dwindling because hospitals and health systems are buying physician groups. Dr. Feinberg and Dr. Wong both noted that it is more cost effective to treat patients in physicians’ offices rather than hospitals.

Cardinal Health has also introduced its PathWare^™ decision transaction tool to influence behavior in a myriad of diseases and help payers and providers choose evidence-based, cost-effective treatments. Dr. Wong said he has considered using PathWare^™, but CareFirst is attempting to develop its own decision support process, so the companies may not collaborate on that initiative.

In the coming months, Cardinal Health will publish results of its oncology partnerships with Aetna and Highmark. Dr. Feinberg said preliminary data show savings similar to those of the CareFirst program. More organizations, including payers and state oncology societies, have recently approached Cardinal Health to inquire about their pathways, although most are cautious about declaring that pathways will soon become standard industry practice.

“We are still a business in its infancy in a market sector that is very much unknown,” Dr. Feinberg said. “It just takes time, I think, for people to be convinced that this is the way of the future.”