Clinical Pathways to Treat Oncology

San Francisco—As costs associated with oncology increase and more expensive drugs are approved, managed care companies are having a difficult time managing care for patients with cancer.

One way to deal with the issue is to create clinical treatment pathways, which are becoming more popular, according to speakers who discussed the topic during a Contemporary Issues session at the AMCP meeting titled Oncology Pathway Development and Implications for Managed Care Pharmacy.

Mark Zitter, MBA, founder and chief executive officer of the Zitter Group, explained that a clinical pathway is an evidence-based approach to care that specifies what interventions should be performed in what sequence for a select group of patients. He said providers or national organizations, not health plans, usually develop the pathways with the goal of reducing variation, improving outcomes, and decreasing costs.

Pathways provide an alternative or addition to common payer responses to dealing with rising oncology costs such as reducing reimbursement to oncologists, increasing the use and restrictiveness of prior authorizations, and mandating specialty pharmacy providers, according to Mr. Zitter.

Mr. Zitter said his company recently surveyed 101 payers and found managing cancer was the highest priority for them, ahead of diabetes, asthma, hyperlipidemia, rheumatoid arthritis, and other chronic diseases.

“This is clearly an issue,” Mr. Zitter said.

The respondents agreed that too much money is spent on cancer care. Payers said they could eliminate 22.7% of costs of cancer treatments without negatively affecting health outcomes in patients, while oncologists said they could eliminate 18% and practice managers said they could eliminate 15.9%.

“Everybody thinks there is a lot of waste,” Mr. Zitter said.

Still, their organizations have not all embraced clinical pathways: 56% of the practice managers, 51% of the oncologists, and 40% of the payers said they had applied pathways to managing cancer therapies. Meanwhile, nearly all of them had implemented prior authorization (99% of practice managers, 90% of oncologists, and 88% of payers), while tying the drug approval to diagnostic tests or biomarkers and listing guideline requirements were also more popular techniques.

However, clinical pathways are expected to become more prevalent. Of the payers who completed the survey and had not implemented clinical treatment pathways, 60% said they would implement or would likely implement pathways in the next 18 months.

The survey also found that healthcare professionals are optimistic regarding clinical treatment pathways: 80% of payers and 61% of oncologists said they agreed that increasing the adoption of clinical pathways would reduce cancer costs.

Among payers who adopted clinical pathway programs, breast cancer (83%) was the most common of the oncology subtypes, followed by lung (70%), colon/rectal (60%), multiple myeloma (43%), prostate (40%), kidney (38%), ovarian (38%), chronic lymphocytic leukemia (35%), liver (33%), and melanoma (30%).

The most common reasons given for not adopting clinical pathway programs were because there was no consensus on which pathways to adopt (15%) and the management techniques are already effective (15%). Other reasons given were a lack of negotiating power with oncology groups (11%), philosophical opposition to practicing medicine (11%), staffing constraints (10%), state law prohibitions (8%), not convinced of return on investment (7%), concern over negative publicity (5%), and the organization does not manage oncology (5%).

Mr. Zitter said oncologists typically develop the pathways, but managed care pharmacists can help by providing information on the latest studies and best practices, and monitoring oncology therapy compliance.

By implementing pathways, health plans may be able to eliminate or reduce the use of prior authorization, according to Mr. Zitter. He said that many plans and other payers believe pathways could be successful because they are designed by physicians.

“This is a much more attractive way of changing care rather than paying less and seeing where the chips may fall,” Mr. Zitter said.

Implementing Pathways

Jeffrey D. Dunn, PharmD, MBA, formulary and contract manager at SelectHealth, said his company has implemented pathways for breast, colorectal, and lung cancers. SelectHealth has also put together a group of employees to study pathways.

Through experience, Dr. Dunn has seen challenges related to pathways, including complexity in comparing drugs to choose for the pathway, a lack of consensus in pathway guidelines, and difficulty in educating and supporting patients. For instance, pathways may be helpful for end-of-life care, but Dr. Dunn said it is hard to tell patients that drugs are not working and they should stop taking them.

Physicians and payers usually collaborate on developing pathway initiatives by utilizing tumor-specific guidelines from the National Comprehensive Cancer Network. They have chosen a limited number of regimens for each tumor type and/or stage of disease, according to Dr. Dunn.

In coming years, Dr. Dunn said there would be an increased focus on comparative effectiveness research as well as efforts to ensure analysis of more data and to identify more outcomes-based, clinically meaningful evidence.