Reducing Cost of Care With Clinical Pathways at a Large Academic Medical Center

J Clin Pathways. 2021;7(10):28-29.

The overall cost of oncology care has been rising over the last 30 years with an exponential rise in the past decade. Among Medicare patients, mean expenditure for patients with cancer was four times higher than those without cancer.¹ Drug prices account for a large share of this rise in cost. Medicare Part B drugs have increased at a rate 5.7 times that of overall Medicare spending.² As a result, the Center for Medicare & Medicaid Innovation has developed value-based models to improve quality and reduce overall cost of care.³ With respect to oncology care, drug costs have been shown to represent the majority of the overall cost of care.⁴ As a participant in the Oncology Care Model, we discovered that drug costs represent most of our total costs—as expected.

In an effort to standardize care, reduce variation, and control costs, clinical pathways have been developed throughout the care continuum. Per the American Society of Clinical Oncology, high-quality pathways should meet certain core requirements⁵: they are evidence-based care maps that are developed and supported by experts in the field, are transparent, and prioritize efficacy followed by toxicity then cost. For patients receiving chemotherapy, clinical pathways have been shown to reduce care variation and cost, adding value to oncology care.^6-8 We set out to determine whether these previous findings, which have been primarily focused on community-based settings, are consistent with the experience at a large academic medical center. This column provides a summary of our methods and findings.

Methods

Our National Cancer Institute-designated cancer center, the Sidney Kimmel Cancer Center - Jefferson Health, implemented vendor-developed clinical pathways for chemotherapy administration in July 2018 to reduce care variation and decrease costs across a growing network of tertiary care centers and advanced care hubs within the Philadelphia metropolitan region.

We reviewed costs related to pathway utilization over a 2-year period (fiscal year [FY] 2019-2020). Utilization is defined as using the pathway tool for clinical decision-making, regardless of whether the pathway recommendations were followed. We analyzed differences in total annual drug cost for patients in three categories: On-Pathway (aligned with pathway recommendation), Off-Pathway (not aligned with recommendation), and No Pathway (pathways not used). Per member per month (PMPM) costs were calculated and a weighted average applied to account for changes in annual drug costs.

Findings

Over the first 2 years of implementation, our utilization rates were 70% and 73% for FY19 and FY20, respectively. When comparing PMPM costs for those who utilized the pathways vs those who did not, we observed a decrease in drug costs with utilization of the pathways. This decrease was more pronounced when clinicians adhered to the pathway recommendations. PMPM drug costs decreased by 8% in year 1 (FY19) and by 4% in year 2 (FY20) when pathways were utilized (On- and Off-Pathway). When clinicians adhered to pathway recommendations (On-Pathway), the drug costs were 11% lower than when pathways were not followed. The annual impact on drug costs when utilizing pathways amounted to $2.45 million in year 1 and $1.77 million in year 2 (Table 1). 

Discussion

In this analysis, clinical pathways use for chemotherapy decision-making decreased overall drug costs. These findings complement a recent study that describes reduced drug cost in a community practice setting, thereby supporting the generalizability of cost reduction through the implementation of clinical pathways.^4,9

While these findings are meaningful and add to the growing evidence base of the value of clinical pathways, there are limitations to this study. ClinicalPath (formerly Via Pathways), which is the pathway tool used at our institution, is updated quarterly based on expert consensus. As a result, situations arise in which new treatment paradigms emerge prior to these quarterly updates. During these gap periods, physicians may order chemotherapy outside of the pathways tool but based on the most updated evidence, thus potentially deviating from pathways and potentially increasing cost of care despite following best practice recommendations. With our current dataset, we were unable to assess if certain treatment decisions that were Off-Pathway or in the No Pathway group were later considered to be on-pathway based on the treatment ordered. Additionally, we did not plan a pre-specified subgroup in order to better understand which practices were primarily responsible for cost discrepancies. Further research will need to be performed to answer these questions. As an example, at a large academic cancer center, disease groups such as the acute leukemia team or hematopoietic stem cell transplant team often do not have clear pathways within the pathway tool, thus limiting the utility of pathway analysis in understanding practice variation and its effects on costs in these groups.

Summary

These results are encouraging and reinforce the potential value of clinical pathway tools for oncologists administering chemotherapy. As described above, ongoing efforts are needed and are underway to better understand why the pathway tool is not utilized more frequently and how we can enhance our utilization rates. In addition, further assessment is needed to determine if these results are similar at other cancer centers to fully realize the impact of pathways on drug costs. We hope that this analysis will better refine our use of clinical pathway tools in oncology with the goal of providing high-value care consistently across all our acute care centers.

References

1. Park J, Look KA. Health car expenditure burden of cancer care in the United States. Inquiry. 2019;56:46958019880696. doi:10.1177/0046958019880696

2. Bach PB. Limits on Medicare’s ability to control rising spending on cancer drugs.
N Engl J Med. 2009;360(6):626-633. doi:10.1056/NEJMhpr0807774

3. Innovation Models. Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services. Accessed November 17, 2021. https://innovation.cms.gov/innovation-models#views=models

4. Hertler A, Chau S, Khetarpal R, et al. Utilization of clinical pathways can reduce drug spend within the Oncology Care Model. JCO Onc Pract. 2020;16(5):e456-e463. doi:10.1200/JOP.19.00753

5. Daly B, Zon RT, Page RD, et al. Oncology clinical pathways: charting the landscape of pathway providers. J Onc Pract. 2018;14(3):e194-e200. doi:10.1200/JOP.17.00033

6. Hoverman JR, Cartwright TH, Patt DA, et al. Pathways, outcomes, and costs in colon cancer: retrospective evaluations in two distinct databases. J Onc Pract. 2011;7(3S):52s-59s. doi:10.1200/JOP.2011.000318

7. Neubauer MA, Hoverman JR, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of non–small-cell lung cancer in the community setting. J Onc Pract. 2009;6(1):12-18. doi:10.1200/JOP.091058

8. Kreys ED, Koeller JM. Documenting the benefits and cost savings of a large multistate cancer pathway program from a payer’s perspective. J Onc Pract. 2013;9(5):e241-e247. doi:10.1200/JOP.2012.000871

9. Jackman DM, Zhang Y, Dalby C, et al. Cost and survival analysis before and after implementation of Dana-Farber clinical pathways for patients with stage IV non–small-cell lung cancer. J Onc Pract. 2017;13(4):e346-e352. doi:10.1200/JOP.2017.021741

Disclaimer: This article is sponsored by Elsevier. The opinions and statements of the clinicians are specific to the respective authors and not necessarily those of Elsevier, Journal of Clinical Pathways, or HMP Global.