Payer Roundtable: Going Beyond Oncology Clinical Pathways

Clinical pathways tend to be associated with oncology, an area where drug prices can be substantial, given their potential for improved outcomes and cost savings. However, pathways can also play a role in other specialty areas with similar outcomes and cost challenges. First Report Managed Care recently spoke with two managed care experts who started out working with clinical pathways in oncology and have since expanded to additional specialties. 

Atul Dhir, MD, DPhil, is the chief executive officer of New Century Health, a specialty management company focusing on cancer and cardiology care. Bruce A Feinberg, DO, is vice president for medical affairs and chief medical officer for Cardinal Health Specialty Solutions, which is known for its oncology solutions, including its pathway programs, but has also demonstrated success in rheumatology.  They each spoke about their start in oncology and the key differences when using clinical pathways in non-oncology specialties.

What has your organization’s experience with oncology clinical pathways been like? 

Dr Dhir: My personal involvement in oncology pathways dates back over 10 years to when I was leading the clinical division of US Oncology. New Century Health is a nearly 15-year-old company. I came on as the CEO about four and a half years ago. We have been implementing oncology pathways since 2011. 

Dr Feinberg: Cardinal Health acquired P4 Healthcare in the summer of 2010, and I was hired in the fall. The acquisition put Cardinal Health in the business of analyzing and reporting important data for both payers and providers.

What made rheumatology well-suited for clinical pathways? 

Dr Feinberg: A Blue Cross client saw the success we were having in oncology. They were having issues with their rheumatology network and asked if we could apply our success in oncology to this treatment area. It began as a great pilot initiative.

Regardless of structure, you have the same need to increase compliance around the consensus. You have to base it on consensus-driven, evidence-based medicine, and then implement pathways so that they can be measured and reported. 

Is there a limit to the specialties  to which clinical pathways can be applied? Could they be applied to all specialties?

Dr Feinberg: It can be applied almost anywhere, but it can have the most dramatic impact in areas with the greatest amount of variance.  Rheumatology is such an area. We saw a payer environment using a drug management approach, not an evidence-based clinical approach.

The providers wanted autonomy in treatment selection. The payer had different issues. They were worried about “dose-creep”, or prescribing in a way that was not consistent with the label.  They were also worried about site of care and wanted to see the drugs delivered in an office setting rather than the hospital. They also had an issue with the use of biologics. 

Do cardiology pathways differ from oncology pathways in any way? 

Dr Dhir: Sure. Oncology pathways have traditionally started with a focus on drugs. The drug component in cardiology is not as big, meaning our focus is on services and procedures: surgery, interventional diagnostics, etc. 

Because of a focus on services and procedures, cardiology pathways tend to impact both hospital and non-hospital outpatient quality and cost. 

In cardiology, by implementing pathways we are having a more systemic effect, whereas in oncology, impact currently tends to be much more concentrated. 

How were you able to bridge the divide between provider and payer? 

Dr Feinberg: My job was to sit down with them and seek common ground. We began with 3 years of claims history from the payer, which we used to spot trends. For example, we saw a particular type of patient who was started on a biologic and then dose-escalated in 6 weeks. We also saw patients started on a nonbiologic disease-modifying antirheumatic drug (DMARD) who rapidly transitioned to biologic agents. We knew from the evidence that you don't get optimization of the nonbiologic DMARD when you transition too quickly. At 8 weeks you might obtain 40% control, but at 12 weeks the control rate may be 60%. Based on what we saw in the claims and knew from the evidence, it made sense to create a rule that patients should be given a full 12-week course before escalating the dose or schedule, or before changing to a biologic.  

Did the providers support those types of changes?

Dr Feinberg: Yes and no. The providers on our steering committee saw the logic but asked for help selling it to the entire provider-base. So we agreed on a compliance threshold of 80%, which allowed for some provider leeway. They liked that, so it ended up being a nice trade-off.

What have the outcomes of expanding clinical pathways to other specialty areas been? 

Dr Feinberg: We found through this program that we could make payers and providers collaborators instead of adversaries. Costs were lowered through increased use of a nonbiologic DMARD by about 10%, label-based dosing, scheduled drug administration, and increased office administration of infusions. More importantly, patient burden of disease and treatment was not negatively impacted.  

Dr Dhir: We have had an even greater impact in cardiology than in oncology. Over a one-year period, with roughly 30,000 Medicare Advantage members, we have seen a 24% reduction in hospitalization as a result of our cardiovascular program. We’ve also seen a 10% to 12% reduction in overall cost.

What important lessons have you learned through expanding the use of clinical pathways?

Dr Dhir: What we learned in oncology helped us to make faster progress in cardiology. Cardiologists have a much broader and deeper source of evidence. Cardiology, as a specialty, has a lay tradition of using decision logic, appropriate-use criteria, and step therapy. 

Just as in oncology, we learned that it's one thing to develop a pathway and quite another to really measure improvement. You have to ensure adherence to these pathways. This is as much an art as it is a science. 

Dr Feinberg: Clinical pathways are complicated. It's easier to sell simple, which may be why drug management programs are more prevalent. It is a hard sell. Even in the face of our validated approach, it is hard to overcome market forces.