Balancing out the provider perspective was Andrew Allan Hertler, MD, FACP, New Century Health, who explained why clinical pathways are increasingly being used by payers as a tool for controlling oncology costs.
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When broken down, cancer costs are 14% due to surgical admissions, 15% surgery, and 20% pharmaceuticals. Oncology drug costs have increased by 48,000%, Dr Hertler said. This, combined with the complexity and variability of treatments, are driving payer concerns regarding oncology treatment. With respect to the variability, this includes variations in the costs of care for patient, which equals unpredictability for payers. Payers are also concerned about providers’ inconsistency with following evidence-based guidelines; only about 66% of care is adherent to the major guidelines, Dr Hertler reported.
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One of the primary challenges to managed care organizations is balancing standardization with personalization, Dr Hertler said. Clinical pathways can help to address this challenge for managing health conditions for which the patient population is large, the treatment options are many, or the most effective treatments are costly. Because patients hold payers accountable for the quality of care they receive, payers often use quality as a way to market their plans. Clinical pathways therefore become part of a payer’s value proposition. For this reason, Dr Hertler predicted, payer-developed pathways will always differ from one another, because this is how payers will differentiate themselves in the health insurance marketplace.
Althought Dr Hertler recognized the administrative burden that multiple pathways pay place on oncology care providers, he also pointed out the ways in which pathways can support physicians in their practices. For one, clinical pathways provide a decision support tool, helping physicians to ensure they are prescribing the most effective, evidence-based treatments. And, as such, clinical pathways will only become more useful as they become more granular. For another, as other speakers also pointed out, adherence to pathways can simplify the reporting of quality metrics. Dr Hertler predicted that prior authorization requirements that currently present the largest burden will go away as models shift away from fee-for-service and towards shared risk.
