Clearing the Air: Exploring Payer Pathway Breadth and Depth

J Clin Pathways. 2025;11(1):57-59.

In Q4 2024, HMP Market Access Insights (MAI) conducted desktop research and an interview program examining promi­nent payer- and provider-developed clinical pathway programs. The purpose of our research was to perform a comprehensive analysis on the values, structures, and processes underpinning these programs. Additionally, we sought to clarify topics where substantial confusion or inconsistency exist among stakeholder groups. This column highlights one of the clarifying analyses we conducted as part of that research.

As part of the MAI research on oncology clinical pathway programs this year, one challenge our team encountered was sorting the myriads of languages pathway developers use to de­scribe their clinical pathway programs. How it is that all payer programs claim to cover 90% of tumors, yet we consistently hear clinical pathway users criticize these for their brevity? How do we reconcile this with what we heard at the 2024 Clin­ical Pathways Congress, where payer clinical pathway develop­ers affirmed that their programs offer a similar level of detail to provider-developed pathways? Notably, Elsevier’s ClinicalPath boasts over 2500 pathways, while the highest number we heard from a payer was 50.

We suspected that many of the discrepancies stemmed from definitional differences and organizations employing similar language to describe highly variable programs. To better un­derstand these variations, we conducted an analysis on the self-reported breadth (eg, the number of tumors or patients eligible for their pathway) and depth (eg, the level of detail within a specific tumor) of payer pathway programs, to identify key dif­ferences, and gain insight into the criticisms they have faced.

We created a unified framework to analyze the clinical path­way programs developed by Optum, Carelon, eviCore, and Evolent. For breadth, we standardized tumor pathways into a consistent framework of 24 tumor categories. For depth, we quantified the distinct biomarkers, lines of therapy, and other factors important to defining treatment strategies for each tu­mor to assess the level of detail in each program.

Most differences in tumor representation definitions come from variations in how payers categorize tumors, rather than differences in the tumors for which they propose treat­ments in. For example, the eviCore, Carelon, and Optum programs list small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) as separate categories. In contrast, Evolent—despite having the broadest representation by our analysis—groups both under a single “lung cancer” cat­egory, with SCLC and NSCLC identified as subcategories.

We observed categorization differences across several other tumors as well, including lymphoma, breast, and gastrointesti­nal cancers. However, our analysis revealed that payer pathway programs share more similarities than differences (Table).

According to our analysis, the depth of payer clinical path­way programs varies significantly across the Optum, Carelon, eviCore, and Evolent programs. The deepest clinical pathway program includes three times as many “branches” as the “shal­lowest” (Figure 1). The clinical pathways for renal clear cell carcinoma illustrate this variability quite clearly. Among the four possible levels of pathway depth, the payer programs ex­amined utilized three. eviCore’s clinical pathway program is only one “branch” deep, Carelon’s contains two, and Optum and Evolent contain all four levels (Figure 2).

Based on conversations with physicians, practice managers, and clinical pathways developers as part of our 2024-2025 Oncol­ogy Pathways Report, we believe that a clinical pathway’s depth is critical when clinical leaders are frustrated with the payer programs. If physicians are expected to use a combination of genetic markers, lines of therapy, and other patient/tumor pro­filing characteristics in determining treatment recommenda­tions, then payer pathway tools also need to align to current treatment paradigms.

When a clinical pathway program omits one of the patient/ tumor variables physicians use in their treatment assessment, the pathway flips from being an assistive tool to a hindrance to timely care. While all payer pathway programs cover most of the same tumors, the large variation in pathway depth can ex­plain why oncology practice leaders express frustration with payer clinical pathway programs and why they are frequently seen as another form of payer utilization management.