Custom Pathways in Oncology: Innovations, Stakeholder Collaboration, and Value-Based Care

James Hamrick, MD, MPH, Vice President of Clinical Oncology at Flatiron Health, highlights the importance of custom oncology pathways in enabling real-time updates for oncologists, fostering collaborative implementation teams, and supporting value-based care to improve patient outcomes and cost-effectiveness.

Transcript:

James Hamrick, MD, MPH: My name is Dr James Hamrick. I am a medical oncologist and Vice President of Clinical Oncology at Flatiron Health. I am thrilled to be attending the Clinical Pathways conference this year, because it's a great collection of stakeholders from different places in the oncology ecosystem and the content up on the stage is excellent. We hear the perspectives that really matter most in terms of transforming care and standardizing care, and the networking is great as well.

How do custom pathways specifically benefit patients, providers, and payers, and what makes them more effective than standardized approaches?

Dr Hamrick: When I think about custom pathways and how vital they are to high-quality oncology care right now, and what distinguishes them from regular standard care, what I really come back to is the incredible amount of innovation that is happening in cancer care right now. I am a general medical oncologist, and something that I feel and that you hear up on the stage is that we are getting all of these great new diagnostic tests and treatments, and it's actually really hard if you're a doctor taking care of patients with all different kinds of cancer—lung cancer, breast cancer, colon cancer, leukemia, lymphoma—to keep up and make sure you're offering the best treatments. What pathways offer is a chance to be updated in real time in your workflow on the latest science and the latest treatments to make sure you're not missing something and you're not missing an opportunity for a better outcome for your patient.

When you envision a successful pathway implementation team, which stakeholders should be part of the team?

Dr Hamrick: A successful pathway implementation team starts with the goal for the team. At the end of the day, we are very fortunate in oncology because everyone, no matter where they're coming from, is in it to try to get a better outcome for the patient. Beyond that, you have to have the buy-in from the local physicians. They're the ones that have to change their day-to-day work more than anyone else to make pathways work, so it’s really important to have physician buy-in. In addition, and this came up in the panel, having a physician champion—someone who has credibility as a fellow physician among their colleagues, who can vouch for the value that the pathways will bring—is super important.

When you think about who else you need, pharmacy is absolutely indispensable. They know the drugs better than anyone else and are really comfortable working in standardization, working with pathways, and dotting the I's and crossing the T's to make sure that the right regimens are in their regimen library and the right treatments wind up being what the patient is able to get. Beyond that, there is a lot of operational work, so you need various stakeholders from within the practice or the health system to be bought in so that there is some formal time and structure built into this. You need Prescription Monitoring Programs (PMPs) for how you're going to update your pathways, what kind of sign off do we need? What you don't want is for it to be something that everyone has to cram in [during] nights and weekends. If you're going to make it work, you have to dedicate the time and get the right team on board.

Based on your session, what do you feel was the consensus regarding best practices that have emerged when implementing custom pathways?

Dr Hamrick: I think the consensus is you have to decide as a unit at your practice, hospital, or health system that this is an investment that you're going to make, and then you really have to carve out the time and the team to make it work. When I think about it, I come back to best practices including getting the physician buy-in from a leadership and champion aspect first, and then involving the local frontline doctors in the decision-making process, because they are the ones who are going to be trying to keep up with the science as best they can. They are the ones that are going to be, at the end of the day, using the pathway to take care of the patients under their care. They are absolutely crucial. At the same time, you have to have operational excellence to make this happen or you can really flail. And then you have to have a mindset of actually tracking things like adoption and concordance with expert guideline rates so we can see where we are and how we're doing.

How do you balance the needs and priorities of patients, providers, and payers to ensure optimal outcomes for each group?

Dr Hamrick: When I think about balancing the interests of the stakeholders when you are trying to implement a pathway system, the good news is that it all really does come back to the fact that everyone—whether it's a patient, a provider, the team making the resourcing decision, or the payer—is working for better patient outcomes and to have it be financially sustainable. So you start from that first principle and then you are able to put together and continue to realign and make sure you can draw a pretty straight line from the day-to-day work you are doing to standardize your pathways and workflows, keeping them updated, and making sure they're delivering optimal care all the time to the higher goal of delivering better patient outcomes and making sure that your site of care is financially sustainable.

What role do custom pathways play in value-based contracting arrangements between pharmaceutical companies and health care providers or payers?

Dr Hamrick: Value-based pathways are an important part of the relationship between the people that deliver the care—the sites of care and the doctors and the payers—and the sponsors that innovate and make great medications. What you really want to do is you want to be able to identify patients who stand to benefit from whatever the therapy is that you're bringing. I've mentioned before, and it came up many times during the panel, that it's getting really complex with the velocity with which new therapies are hitting the market, with more than 40 newly approved FDA indications per year for the past several years. It behooves all of us to understand who are the cohort of patients who will benefit from those [therapies], and how can we make sure that they have the best chance of receiving them? Pathways are simply a tool to do that. Especially for a busy general medical oncologist who is trying to keep up, a pathway can be a technology safety net to make sure that they're aware of the latest innovations, and that works for all of the stakeholders. Chances are, if you are delivering the care that is likely to give the best outcome, eventually your overall cost of care is going to come down. And of course, what you're getting for that is the best possible outcome for that patient.

What is one key takeaway you hope the audience gained after attending your session?

Dr Hamrick: After attending our session about building your own pathways, I think the first thing that people should understand is that it is an investment worth making. We do not live in the world we lived in 18 years ago when I finished fellowship, where there were not that many new therapies coming out. It’s a completely different world and it's an exciting one because we know so much more about tumor biology and how to treat it. But it's absolutely vital that people understand that you're not going to be able to succeed in giving your patients the best outcome if you don't have a systematic approach that's engineered to give a higher percentage chance that your doctor is going to make the best decision for their patient. Pathways are vital to good care in today's oncology environment. And then, as I said on stage, it's a major investment. I would not kid yourself that this is something that can be done on nights and weekends. You have to decide to put in the resources and assemble the team to execute it.