NASP: Affordable, Quality Cancer Care Will Rely on the Use of Pathways

Future cancer care will depend on the use of pathways in order to achieve a goal of acces­sible, affordable high-quality care, according to information presented by industry leaders at the 2015 NASP Annual Conference. The cost of cancer management is increasing at a rate 2 to 3 times that of other therapeutic areas, with a current total of more than $23 billion.

Cancer management is characterized by a host of challenges that include an increasing patient base, more complex treatment regimens and extended time on therapy, and declining resources (eg, on­cologists). Value must be the focus of the oncology solution, Michael Kolodziej, MD, national medical director, Oncology Solutions at Aetna, explained. If value equals quality over cost, quality must consist of guideline-based therapies, targeted impact, low toxicities, improved survival, and improved quality of life. Cost encompasses best supportive care, avoidance of hospital days and emergency department visits, and decreases in site of service costs and medically unnecessary care at the end of life.

The implementation of pathways requires an evi­dentiary and operational process along with mea­surement and reporting, he continued. Pathways are favored by payers because adherence to evidence-based guidelines decreases cost without negatively impacting treatment efficacy.

Dr Kolodziej cited results from a pilot program that implemented a clinical decision support system that showed a 43% relative improvement in adherence to evidence-based treatment selection. Treatment options in the study were sourced from leading oncology guideline bodies, such as the American Society of Clinical Oncology and the National Com­prehensive Cancer Network, and were selected for 25 more patients for every 100 cancer patients in the study.

Enabling physicians with clinical decision support tools helps improve care, reduce costs, and maintain qual­ity. Dr Kolodziej cited an oncology pilot study of 156 physicians in 7 locations that reduced treatment variability by 28% and increased generic-only utiliza­tion in regimens by 11%. Net savings were $393,599 resulting from reduced emergency department visits, inpatient hospital stays, and spend on certain drugs. Pushback from oncologists on the use of pathways is common, how­ever, for a variety of reasons including administrative burden and an “I know better” mentality. But, in Dr Kolodziej’s opinion, pathways can lead to care de­livery reform, reimbursement reform, and personalized medicine. “Path­ways bring structure to the manage­ment of cancer patients. They promote evidence-based, value-driven treatment choices in the short term, but ultimately will be the engine that drives personalized, precision care,” he said.

Cancer care today is fragmented and often not patient-centered, evidence-based, or coordinated. In a presentation focused on whether guidelines are working, Debbie Stern, RPh, of eviCore healthcare, cited that 1 in 3 patients treated with chemotherapy do not receive a treatment plan consistent with current medical evidence. Among the most common drivers behind off-pathway prescribing, she said, include inappropriate drug combinations within a regimen and genetic testing not being done when indicated. A variety of complex specialty drug management challenges have been identified by payers, as they look to other supportive service vendors to assist. These include managing oncology, determining the value of therapy, managing the appropriate use of therapy, coordinating management across pharmacy and medical benefits, and pipeline/new product approvals.

Pathway programs involve a variety of vendors and are differentiated by their clinical source, ease of use/physician acceptance, authorization capabilities, ownership/potential conflicts of interest, and inclusion of multiple treatment modalities (eg, lab/genetic testing, radiation therapy, advanced imaging, and end-of-life care).

The stronger the pathway enforce-ment, Ms Stern told attendees, the higher the savings and quality. Pathways can enforce best practices, as newly published data can be incorporated into them. But point-of-care, real-time decision support tools can be a pathway compliance solution only when they are used. Low adoption rates and usage are currently limiting the benefit of this technology.

At eviCore, Ms Stern said, their medical oncol-ogy pathway experience has resulted in more than 98% clinically appropriate approvals and savings opportunities of 8% to 20%, depending upon the client.—Mary Mihalovic