Highlights of the 2022 Clinical Pathways Benchmark Survey

J Clin Pathways. 2022;8(8):24-26.

The goal of the 2022 Clinical Pathways Benchmark Survey is to gain insight into the evolving landscape of clinical pathway use in oncology practices today. The relevance of knowing how pathways are utilized today is driven by our knowledge that clinical pathways are an integral part of oncology care. The reasons for the continued interest over the years have changed, driving practices to improve their quality and efficiency of care, especially with the ongoing transition to alternative and value-based care models.

At a high level, this year’s benchmark survey results indicate that clinical pathways are increasingly being utilized as a tool to improve clinical outcomes and control costs. We asked some different questions this year, based upon responses from past surveys and our findings from the 2021 Care Pathways Working Group.¹ Presented here are the highlights of our 2022 survey results, as presented as part of the Oncology Clinical Pathways Congress in Boston in October.

The survey was distributed via email to the Journal of Clinical Pathways and Oncology Learning Network digital audiences, and the respondents were of similar composition as past years. Approximately, 80% of the respondents were direct oncology-related care providers, dominated by medical and radiation oncologists. Possibly indicating that interest in the use of clinical pathways is growing outside of the oncology arena, 14% of our respondents were non-oncology care providers. The practice size shifted a bit from last year, representing a more even mix of small, medium, and large practices. Last year, results were skewed toward the medium practices; the new leveling could be due to the continued consolidation of the community practices with health systems or integrated delivery networks.

Traditional fee-for-service (FFS) was the predominant payment model for the responding practices, increasing from 32% in 2021 to 70% in 2022. We noted a decrease in pay-for-performance and full and partial financial risk models. Bundled/episodic payments and specialty accountable care organizations appeared to hold steady. It bears noting that the increased FFS payment model does not necessarily indicate unmanaged care. Quality and financial goals can still be in place, monitored by the internal practices, or by payers for report carding, and not necessarily tied to a formal performance-based reimbursement as we
see in some medical home models.

The future interest in pathway implementation that we saw in 2021 appears to be in motion. Pathway programs currently in place jumped from 37% in 2021 to 53% in 2022. Coupled with the increase in current pathway programs in place was a decrease in practices planning to implement new programs in the next 12 months and beyond, possibly confirming that those programs planning to implement last year have followed through. Small to medium practices may account for the increase from 9% to 12% that remain resistant, due to financial and resource requirements associated with pathway program implementation as well as referring more difficult cases to local health systems or cancer centers.

Respondents were asked to rank various reasons why pathway programs were put into place, categorizing them into one of four categories by level of importance: 1) “Not a Factor,” 2) “Somewhat Important,” 3) “Very Important,” and 4) “Most Important.” From a high level, the primary drivers have not changed significantly. Most of the primary drivers remained in the “Very Important” category. However, what did shift are the secondary drivers, advancing from the “Somewhat Important” to the “Most Important” category, indicating a greater pressure for accountability. Specific notable shifts included “Payer Reimbursement” advancing from the “Somewhat Important” to “Very Important” and “Improve Clinical Outcomes” moving from “Very Important” to “Most Important.” Overall, what we are seeing is the need for clinical pathways as a tool to improve outcomes and control costs (Table 1).

Similar to last year’s results, 40% of the respondents are allowed to take social determinants of health or patient preferences into account, even if the final treatment decision is “not preferred” without concern of the treatment decision counting against their performance. This indicates that oncology care is continuing to refocus back to the patient, although specific patient preferences and social determinants may not be built into the pathway decision tree.

In a reverse move from last year, 70% of the respondents indicated that their pathway content is primarily being driven by the National Comprehensive Cancer Network (NCCN) Guidelines or other recognized compendia, and away from third party vendor proprietary pathways. It is also possible that third party vendors are accommodating the NCCN Guidelines as a decision source. We also observed a decrease in internally driven programs as well as health system-driven programs.

Administrative burden is frequently cited as a concern, especially when practices are subject to multiple programs. For the most part, the practices interface with one to two nonaffiliated health system/network pathway programs. However, the number increased to three to four pathway programs with respect to affiliated health system programs. This interface with multiple affiliated health system programs may be representing a regional perspective for patient referrals, where there may be several affiliations with different health systems, hence a commitment to participate in the system’s pathway program. The need to affiliate with several health systems may be payer driven. Not unexpectedly, payers top the number of interfaced programs with six or more programs in place, thus contributing to the workflow burden. Community practices will participate in multiple payer networks, and will be subject to their utilization management programs.

We took a dual approach with program administrators. We first asked administrators of payer programs. We observed “Blue” penetration with AIM Specialty, a subsidiary of Anthem BCBS, having the line share at 29%, followed closely by United Healthcare (UHC) at 28%; AIM and UHC are followed by a fairly even split between EviCore (part of Cigna’s UM subsidiary Evernorth), New Century Health, and OncoHealth (formerly Oncology Analytics). From the practice administrator perspective, NCCN value pathways is the predominant administrator of the practice programs, followed by EPIC, In-House technology, McKesson (formerly US Oncology), and ClinicalPath (formerly ViaOncology).

Looking at the comprehensiveness of pathway programs with respect to the number of cancer types covered, half of the respondents utilize the full set of NCCN Guidelines for all cancer types and treatment options. For those programs whose pathways were a subset of the NCCN recommendations, a greater number of respondents indicated that they were allowed to use an all-regimen-options list with no restrictions or barriers as opposed to those who were subject to medical director approval prior to administering a non-list regimen. From the perspective of clinical and patient support content, we observed increases in radiation oncology inclusion, most likely in the larger multisite practices. Supportive care, predictive and prognostic genomic profiling, palliative care patient determinants, and nurse navigation inclusion all increased in 2022, although they are not yet at levels that indicate widespread adoption. The genomic profiling inclusion, specifically the predictive testing, is interesting as we are in an age of personalized medicine where so many of the new targeted and novel medications are being approved with companion diagnostic testing requirements, and we are seeing increased payer coverage of these test. Yet, wide inclusion in pathway decision trees is less than 40%.

With the percentage of self-administered medications increasing as a treatment option, our respondents indicated that more than 50% of the pathway programs included both self-administered and infused treatment options; however, a fair share of the programs only include office-administered treatment options. The NCCN Guidelines include both oral and infused treatment options; hence, the results are not surprising. We can only assume that the programs that include only infused treatment options are the older programs that are still in place. We did not dive into the integration with the pharmacy benefit in situations where it was noted that both self-administered and office-administered options were listed; however, we know from our knowledge of the pathway landscape that there is little to no integration between pathway administrators and the pharmacy benefit.

It was noted earlier that one of the driving factors for pathway implementation was to reduce overall cost of care. We sought to learn if the use of biosimilars was an active management inclusion. It has been well documented that the promotion of biosimilars has the potential to significantly reduce medical claims cost on a per-member-per-month basis compared to a population with no active management. More than 60% of our respondents indicated that biosimilars were actively promoted as part of their pathway treatment options.

Compared to 2021, fewer respondents felt that their practice pathway programs were more stringent than payer programs (34% in 2022 vs 51% in 2021). Confirming this perspective, a greater number of respondents indicated that their practice pathway program had the same level of stringency (increase from 21% in 2021 to 40% in 2022). This is consistent with the NCCN Guidelines being used as the primary content driver and administrator. It bears noting that payers use the NCCN as one of their primary sources for coverage determinations, along with approved FDA indications, thus the change in positioning confirms this observation.

Standardizing treatment decisions, improving quality of care, and controlling costs remain the top perceived benefits of a clinical pathway program. Respondents felt that there was an importance to pathways assisting them as an educational tool, which didn’t necessarily coincide with improving the satisfaction of the oncologists in their role as a mitigation factor to provider burnout. Finally, even though the implementation of a pathway program can represent a major practice workflow burden initially, especially if the program is payer driven, it is felt that the benefits of that program balance out the additional administrative burden.

In conclusion, the responses indicate a continued interest in clinical pathways, most likely associated with increased demand for improved quality of care and financial accountability. FFS reimbursement increased over 2021; however, this does not mean that quality and financial tracking, as part of performance-based reimbursement and risk-bearing arrangements, are not in place. Clinical pathways are still based upon efficacy and tolerability. Off-pathway utilization is allowed for patient preferences and social determinants; however, they are most likely not to be built into the clinical pathway decision tree. Finally, there is still a perception that clinical pathways can improve the quality of care and control costs, and the use of pathways will increase in the future.

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Authors: Winston Wong, PharmD, Editor-in-Chief

Affiliations: Journal of Clinical Pathways