As the insurance industry scrambles to adapt to health reform legislation, the use of cancer care pathways is emerging as a strategy that may help control its oncology costs.
Three pathways companies—Innovent Oncology, P4 Healthcare, and Via Oncology—are actively marketing their services to insurers, and others are expected to come on the scene. Clinical pathways, the vendors say, offer the opportunity to improve the quality of cancer care while reducing costs.
That is a message that resonates with payers, who are under intense pressure to improve quality and bring health care costs to a sustainable level. Richard Popiel, MD, MBA, Vice President and Chief Medical Officer at Horizon Blue Cross Blue Shield of New Jersey, says urgency is essential.
“Most leading health plans, if they are not at a sustainable trend rate within five years, are going to be at great risk either of not being competitive or not being sustainable. So plans like ours are embarking on a broad-based process to completely transform how we engage with our membership, our doctors, our hospitals and our vendors, and this will be reflected in, and perhaps driven, by payment reform.”
For Horizon, that means trying out clinical pathways as a route to lower its cancer care costs. Horizon is sponsoring a pilot program with two New Jersey oncology practices to explore the use of Via Oncology pathways.
P4 Healthcare, through an arrangement with Blue Cross Blue Shield of Michigan and OPR, a physician organization that represents 64 Michigan oncology practices, is working to develop a clinical pathways program. Clinical pathways for lung, breast, and colon cancer, as well as supportive care, will be made available to oncologists throughout Michigan. P4 also has arrangements with CareFirst BlueCross BlueShield, which insures people in Maryland, District of Columbia and Virginia, and Capital BlueCross, which serves central Pennsylvania.
Innovent Oncology, a service of US Oncology, just signed a contract with Aetna to bring its pathways program, along with proactive patient management and advance care planning, to cancer patients throughout Texas. The agreement is expected to expand to 20 other states throughout the country.
Meanwhile, several individual oncology practices around the country are developing pathways on their own, with the goal of negotiating better contracts with their payers.
The Promise & the Problem
The first promise of oncology care pathways is that they reduce the wide variation in current oncology practice with guidelines that provide the best patient outcomes. Although clinical pathways are developed in various ways, the basic idea is that scientific evidence is used to create treatment pathways that offer the combination of the greatest survival benefit and the lowest toxicity.
The second promise is that, by reducing variation, curtailing the complications associated with poor care, and eliminating the use of ineffective treatments, the cost of cancer treatment via pathways may be substantially lower than current practice.
Physicians in the US Oncology network earlier this year published a study with Aetna that found that annual outpatient costs for non-small-cell lung cancer patients treated with Level I Pathways were 35% lower than those patients treated “off pathway,” with no difference in 12-month overall survival (Journal of Oncology Practice 2010;6:12–18). This study provides evidence that high-quality care is not necessarily associated with high cost.
Meanwhile, IntrinsiQ, an oncology data and analysis firm, reviewed the actual treatment decisions made by the 700 oncologists who use its Intellidose chemotherapy ordering software and compared them with the Via Oncology pathway protocols. That analysis found that payers would have spent 40% less on oncology drugs if the pathways had been followed in all cases, said the company's President, Kathy Lokay.
Adherence to a clinical pathway is not appropriate in all cases; if the Via pathways had been followed in 80 to 85 percent of the patient scenarios, payers would have seen their drug costs cut by 32 to 34 percent.
The problem with cancer care pathways is getting oncologists to follow them. The vast variation in treatment patterns that exists today is evidence that oncologists disagree on which therapies offer patients the best outcomes.
While some oncology leaders are able to get their colleagues on board with a pathways program, that is not easy in a single practice, let alone an insurer's entire physician network. That is why Horizon BCBSNJ will launch a pilot program this summer.
Dr. Popiel described the New Jersey oncology community as a “a mix of solo practitioners, small groups, and several academically affiliated groups.”
Beginning in July, the nine physicians who practice at the Center for Cancer and Hematologic Disease, the largest oncology practice in southern New Jersey, will start a six-month pilot in which they agree to use Via pathways for at least 80 percent of eligible patients.
“This is a pilot to test whether physicians will use this, how they feel about it, and whether it's effective or not,” Dr. Popiel said.
Hematology-Oncology Associates of Northern New Jersey in Morristown, NJ, is joining the pilot later this year, allowing Horizon to learn whether physicians are amenable to the pathways approach. While it may take some time for physicians to embrace clinical pathways, Dr. Popiel predicts pathways will eventually become widely accepted.
“Pathways are just taking what should be the standards of care and organizing them in ways in which physicians can use them,” he said. “And if physicians aren't practicing the standard of care, they're not practicing good medicine.”
Implications for Oncology Payment
It is clear that the use of clinical pathways will change how oncologists are paid, but it is not clear exactly how that will play out. Since most oncologists are paid in relation to the amount and cost of drugs they prescribe, the dramatic savings that insurers see from adherence to clinical pathways translates into a dramatic pay cut for oncologists.
James J. Badaracco Jr., Executive Director of The Center for Cancer and Hematologic Disease in southern New Jersey, said Horizon is paying Via Oncology for some of the costs associated with the pathways program, and Via will pass along some of that amount to his practice. Physicians will see no change in their reimbursement during the pilot. At the end of the trial, both parties will assess its success.
“Depending on whether we like [the pathways program] and Horizon likes it, we would go forward with a slightly different reimbursement model,” he said.
While those details of a different reimbursement have not yet been discussed, he assumes that the practice would be paid more for its non-drug-related services.
Capital BlueCross, the leading health plan in central Pennsylvania, recently signed with P4 to develop pathways for the oncologists in its service territory. Its pathways program will include breast, lung, and colon cancer plus symptom management and conversations about treatment options and end-of-life options.
Christopher Rumpf, MD, Capital BlueCross's Chief Medical Officer, said the pathways initiative was undertaken in response to concerns, both internally and from employer clients, about what constitutes high-quality oncology care.
“This is a quality program, and this is distinct from our reimbursement policies,” he said. “We do know that oncologists are underpaid for administration and treatment planning and patient education. That needs to be fixed, and we are pursuing those [issues] separately.”
The first three organizations to market a pathways approach all have their roots in the oncology community.
- Innovent Oncology is a service of US Oncology. Its Level I Pathways are developed and maintained by physicians, and about 1,000 oncologists are using them. Physicians use decision-support tools such as US Oncology's proprietary electronic health record or a web portal to help select the most appropriate treatment and to track and benchmark pathways performance.
- Via Oncology is a wholly owned for-profit subsidiary of the University of Pittsburgh Medical Center, and UPMC oncologists developed its pathways. (The UPMC oncology group was formerly affiliated with US Oncology, and Ms. Lokay, Via Oncology's President, was a top executive at US Oncology, including head of Innovent.) A web portal enables oncologists to apply Via Oncology pathways for decision support and to monitor adherence.
- P4 Healthcare was started by a group that includes Jeffrey Scott, MD, an oncologist who cofounded Georgia Cancer Specialists and later International Oncology Network. The P4 Pathways program provides software, consulting, and training that allow a group of oncologists in a specific insurance network or geographic region to develop pathways and monitor their use.
Dr. Scott said he expects to see pathways programs coming from many other sources—pharmacy benefit managers, group purchasing organizations, and even state medical societies—as awareness grows about the twin benefits of improved care and lower costs.
But even those who see clinical pathways as inevitable for oncology wonder how the evolution will occur.
“Pathways are being talked about almost like a given now,” Ms. Lokay said. “Because they are finding that all pathways are not created equal, oncology groups and payers are turning their attention to assessing which pathways program is the best.
“And the other big question under discussion is crafting a business model that will work. The challenge is to change reimbursement so that savings from adoption of pathways are shared.”
She said she finds forward-looking physicians more open to clinical pathways than are payers, who worry that physicians cannot be trusted to hold themselves accountable. Payers typically want to monitor physicians' compliance themselves.
“In our model, we are asking payers to set aside external review if oncologists adopt pathways,” she said. “So what we're really selling to the payer is results.”
Mr. Badaracco, of The Center for Cancer and Hematologic Disease, said the physicians in his practice have mixed enthusiasm for the pathways approach, but agree that they need to get experience with a concept that is gaining traction.
“It's our thinking that we would like to be leaders rather than followers for when things change, and we know they are going to change,” he said.” And we would prefer to be on board and be prepared for it.”