The Journal of Clinical Pathways (JCP) conducted its third annual survey to better understand pathway use in US oncology practices and cancer centers. Each year this data continues to provide a wealth of information on how health care providers in organizations of all sizes utilize pathways to influence and improve patient care as well as to enable data collection to assess quality, outcomes, and financial impacts. Respondents are real-world pathway stakeholders who answer an array of questions related to general care delivery; specific reimbursement models; and pathways perspectives, design, use, and collected pathway data.
In 2020, we have seen community practices continue to either close or consolidate with larger health systems, the fragmentation of health care services due to mandated lockdowns, the reduction of face-to-face visits, and the explosion of telehealth medicine. Institutional health care facilities were filled to capacity as we saw multiple spikes in COVID-19 hospitalizations. One would surmise that, in these dire times, clinical pathways programs would not be on anyone’s radar screen; however, we learned that the use of clinical pathways in oncology continues to evolve, with a strong movement toward alternative care models and a focus on value-based care. Clinical pathways have remained pertinent, and as such, we remain committed to better understanding the evolution of their use to create a vision for the future.
Survey Methodology
The 2020 clinical pathways benchmarking survey was developed with input from the JCP Editorial Advisory Board. It included questions focused on respondent demographics as well as questions focused on respondents’ use of clinical pathways within their organization.
Invitations to respond to the survey were sent via email to the JCP and Oncology Learning Network digital audiences. We saw a wide array of respondents (Figure 1), including medical oncologists, surgical oncologists, radiation oncologists, pharmacists, physician assistants, nurse practitioners, patient care nurses, nurse navigators, cancer center and pathway administrators, and non-oncology physicians. This indicates that there is interest in clinical pathways being utilized by other health care provides beyond that of the treating oncologist and that there is interest in clinical pathways outside of the oncology arena. 
Respondent Demographics
A total of 185 people responded to the 2020 survey—over twice the number of respondents from last year and with a greater diversity of respondents. The number of surgical and radiation oncologists increased, as did direct patient care nurses and nurse navigators. There was even a patient who responded to the survey. Most respondents (92%) were direct care providers. Over one-third (41%) were medical, surgical, or radiation oncologists; and 29% were non-oncology physicians (Figure 1). Nurse practitioners, physician assistants, and pharmacists made up most of the remaining respondents, with 4% of the others identifying as cancer center/pathway administrators.
There was a continued shift in respondent demographics from community practice to institutional settings. The percentage of respondents from community practices was down this year, with 26% from the current study vs 30% in 2019. Most survey participants (68%) worked in an institutional setting, such as a hospital, health system, or academic center; the remaining 9.4% worked in an “other” setting (Figure 2). In the survey, about 35% of participants practice in a setting with fewer than 5 oncologists, while 30% work in larger practices with greater than 15 oncologists. The in-between 
range consists of about 34% of respondents working with 6 to 15 oncologists (Figure 3). 
Payment Models
From a financial point of view, fee-for-service (FFS) continues to be the predominant reimbursement model used, at 65% compared with 64.9% last year (Figure 4). There is a continued movement toward performance-based/value-based financial arrangements, including partial risk arrangements (12% in 2019 vs 19% in 2020), full-risk arrangements (9% in 2019 vs 16% in 2020), as well as bundled arrangement (13% in 2019 vs 23% in 2020). In 2019, 25% of our respondents reported a payment-for-performance model, which has increased to 37% this year. 
Another increase from 2019 were facilities accepting bundled payments or compensation for episodes of care—up to 23% from 13.5% last year. These are clear indicators of increased accountability for the care being provided: 33% reported involvement with the Medicare Merit-based Incentive Payment System (MIPS) program, and 12% are participating in the Center for Medicare & Medicaid Innovation (CMMI) Oncology Care Model. Respondents unsure of the payment model used at their institution accounted for 10% of responses. Responses added up to more than 100% as some facilities utilized more than one payment model.
Clinical Pathways Utilization and Content
The current survey showed a shift in the level of oncology clinical pathway utilization from 2019. The 2020 survey showed that 48% have a clinical pathway in place (Figure 5), compared to 66% of practices from the 2019 survey. The percentages of practices planning to implement pathways in the next 12 months decreased by half (down to 7% from 14% in 2019). The percentages of practices planning to implement pathways in more than 12 months is about the same (5% in 2019, 4% in 2020). Those with no current plans to implement clinical pathway use increased to 20% of respondents (up from 12% of respondents last year). While telling, the results of this utilization question could be skewed by bias. Those responding may be polarized to respond due to “use” or “non-use” of pathways. Those who are indifferent may not be motivated to respond, such as those at small or medium practices. The 2019 survey revealed that small to medium cancer centers and health systems may not be implementing a clinical pathway program due to financial or resource limitations. As seen in the size breakdown, a little over 60% of the respondents worked in practices of less than 15 oncologists, so this could be a contributing factor to the increase in responses indicating a lack of clinical pathway implementation plan. Another possible reason for the leveling off may be due to the continued practice consolidation movement among community practices, which are either becoming part of larger health systems or simply closing down. 
The rationale to implement clinical pathways are similar to 2019 responses (Table 1). Payers are a driver of pathway utilization, due to reasons mainly tied to reimbursement. Improved clinical outcomes was the most important driver to implement clinical pathways. Providers are also now pushing for pathways due to rapidly evolving research and treatment options, resulting in the inability to keep up with the latest treatment options. Treatment documentation, reducing variability, and cost control continue to drive pathway utilization as well. All these surveyed factors have some influence on the decision to implement pathways. 
Overall, clinical pathways are becoming more comprehensive in terms of clinical and patient support content (Figure 6). The prevalence of radiation oncology pathways decreased to 38.8% this year from 50% last year. Unexpected lower responses for medical oncology and radiation oncology, compared to 2019 results, may be due to the diversity of respondents of the survey this year. Many pathways feature medical oncology, with 87.8% including pathways for solid tumors and 73.5% including hematologic malignancies. This year, 42.9% of respondents said they offer pathways for surgical oncology (compared to 36.8% last year) and 51% have pathways for supportive care (compared to 31.6% last year). Supportive care is now documented for accountability, which may account for its significant increase. Genomic profiling (predictive companion testing) increased to 34.7% this year from 26.3% last year whereas genomic profiling (prognostic) decreased from 34.2% in 2019 to 26.5%. A greater need for companion diagnostic guidance with so many new target and novel medications being approved may explain this change. A greater appreciation for nurse navigation may have led to an increase in its inclusion (up to 22.4% from 15.8% last year), especially in the times of a pandemic where there is a greater need for patient coordination. 
Of the respondents utilizing clinical pathways, 55% reported adapting National Comprehensive Cancer Network (NCCN) treatment guidelines or other recognized compendia (Figure 7), up from 42.1% last year. Internally developed, committee-driven pathway development was reported at 35% of organizations, up from 23.7% last year. Fewer respondents (2%) indicated their organization outsourced development to a third-party vendor. One explanation could be that, with continued consolidation of community practices into larger practices and health system models, these practices are forgoing third-party vendor programs in favor of strategic partnerships to create their own treatment recommendations. These programs appear to be moving back toward using guidelines and compendia as the base, and then pairing down the treatment options based upon the needs and demands of the practice. 
There is no doubt that pathways are being utilized to increase the level of accountability with providers. A large portion (78%) of respondents utilize the pathways to track individual prescribing patterns, compared to 55% in 2019. Of those tracking prescribing patterns, 51% cannot prescribe off-pathway without peer-review approval (compared to 49% in 2019), and 10% are not allowed to prescribe off-pathway at all (similar to 2019). There was a decrease in off-pathway prescribing allowed without peer review compared to 2019 (32% and 47%, respectively). Respondents (49%) indicated that consistency with pathways is encouraged through peer review and not through financial penalty. Finally, access to the pathway is either through electronic medical record (EMR) or electronically through a separate web-based system (Figure 8). 
Perception of Clinical Pathways
Clinical pathways are viewed to have a beneficial impact upon treatment decision making, improving the quality of care and outcomes, and streamlining data collections, as these remain the top-perceived benefits of a clinical pathway program (Table 2). Cost control is a lower driver compared to 2019, possibly due to the shift from FFS reimbursement to an overall performance/outcomes-based reimbursement. Clinical pathways were indicated to be very important for payer contract discussions, representing a basis for value-based/performance-based reimbursement negotiations. 
Impact of the COVID-19 Pandemic
Given the current global pandemic, a few questions were added to help determine the impact of COVID-19 in respondents’ practices. The number one phenomena experienced by practices is the implementation of telehealth services (Figure 9). Prior to COVID, only 22% of respondents had any kind of telehealth service capability
(Figure 10), and with this in place, the majority of practices had less than 10% of the patient visits being virtual. As a result of the pandemic, there is a significant increase in percent of patient visits now being conducted virtually (Figure 11). 
This is directly correlated with a decrease in the number of patients seen per day, most likely limiting face-to-face visits with treatment administration. Practices are experiencing treatment delays, and patients are experiencing delays in definitive diagnosis. Practices are also experiencing the need for patient prioritization and implementing changes in treatment plans.
Several interesting write-in comments were received, one of which stated that “COVID has changed very little in our practice. Patients don’t socially distance and no screening is done. Masks are enforced.” Another respondent wrote in that there was “less collaboration with colleagues; limited on-site support as ancillary services all work remotely; and decreased patient support as family members are mostly not allowed to company patients to visits.”
Finally, respondents were asked if COVID-19 has modified their pathway programs in any way. Two-thirds of respondents reported no change, while the remaining one-third reported modification. Of the one-third reporting a modification, some of the changes made included: patient prioritization; patient refusal of annual cancer checking procedures and patients missing appointments; each individual case now being based on the future developments of COVID-19; modified treatment recommendations occurring informally as opposed to formally; patients with metastatic diseases are seeking less frequent chemotherapy regimens; prioritization of oral regimens over intravenous regimens to decrease clinic visits (even if the oral regimens are not associated with better outcome); shortening of treatment time; and increased use of growth factor support.
Discussion
In summary, the responses received from the 2020 survey confirm continued facility consolidation in the oncology practices arena. FFS reimbursement continues to be the primary reimbursement model, with continued movement toward performance-based reimbursement, partial/full financial risk models, and bundled payments. Clinical pathways are becoming more comprehensive, moving beyond just sequencing medication regimen treatment options. More pathways are including companion diagnostics, supportive care, and nurse navigation. Respondents still have the perception that clinical pathways can improve the care quality and outcomes, streamline data collections, and control costs. Finally, the COVID-19 pandemic has also had an impact upon patient care and treatment selection as many facilities embrace telehealth and minimize cancer patient visits, but the pandemic seems to have not led to a decrease in pathways interest.
So, what do we project for the future? Looking to the future, given that COVID-19 is still upon us and does not appear to be subsiding soon, we can be sure that the new environment and health care landscape that we are currently working under will most likely become the new “norm,” at least through the majority of 2021. Even if the vaccines are true to their publicized efficacy and , even after the details of the clinical trials are reviewed and scrutinized, the first doses will most likely be arriving at the end of 2020 and into early 2021. These doses will be initially rationed out to first responders and health care workers. Mass availability of the vaccine to the public is not anticipated until mid-2021.
What does all this mean for clinical pathways and oncology care? The impact to the oncology arena, as well as the rest of the health care industry, is that the new systems and processes put into place in 2020 will continue and become the “norm,” ie, optimized care through telehealth and other streamlining strategies. We will see further consolidation of oncology practices, further expansion of telehealth services, and possibly continued fragmentation of health care services, presenting a greater need for patient tracking and navigation services as well as tools like clinical pathways to maintain high-value, high-quality health care while still controlling costs. In addition, we can expect to see the expansion of clinical pathway development beyond the oncology arena and into chronic care conditions, especially as telehealth gains momentum and patient tracking becomes a key factor for achieving improved outcomes and patient satisfaction, while still controlling cost. The return on investment for existing pathways programs continues to be demonstrated, and new reimbursement models require tools that improve care while controlling variation, resource utilization, and costs.
