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Pathway or Pathways? Major Pennsylvania Insurer Takes a Stand, But Now a Long-Time Partnership Has Turned Difficult

Butcher, Lola

doi: 10.1097/01.COT.0000390555.30339.c0


An important test of the concept of cancer care pathways is playing out in Pennsylvania, where a long-time pathways partnership has turned difficult.

For the past five years, Highmark Blue Cross Blue Shield, the largest private insurer in the Commonwealth, has been working with oncologists at the University of Pittsburgh Medical Center (UPMC), the region's largest provider of cancer care, to develop and implement standardized cancer care pathways.

Through that relationship, two studies of Highmark members—one involving lung cancer patients and the other breast cancer patients—addressed the question everyone wants to know: Can the use of standardized treatment protocols—i.e., pathways—significantly reduce the total cost of cancer care without diminishing patient outcomes?

Neither of the Highmark/UPMC studies has yet been published, but Highmark's plan to expand its use of cancer care pathways signals to every other insurer in America that this concept has value.

Earlier this year, UPMC created a for-profit subsidiary, Via Oncology, to market UPMC pathways to oncologists and to insurers who wish to incentivize the use of pathways. Via is the third vendor to enter the pathways marketplace, following P4 Healthcare, a subsidiary of Cardinal Health, and Innovent Oncology, a subsidiary of US Oncology.

While Highmark's work with UPMC oncologists has convinced the insurer that pathways hold promise, the company does not plan to sign a contract with Via and is considering a contract with its competitor, P4 Healthcare.

“We have been looking for ways we can take the concept of pathways, tie it to reimbursement, and spread that to our entire network,” said Robert Wanovich, Highmark's Vice President of Pharmacy affairs. “That's what led us to explore P4 Healthcare as an external vendor to help us do that.”

In fact, Wanovich says, the idea that UPMC's pathways could be adopted throughout Highmark's market was never considered. For one thing, although UPMC is the market's largest provider of cancer care, the other oncologists in Highmark's network are UPMC competitors.

“The reality is that it is unlikely that every other institution in our network will readily adopt what UPMC has decided. In fact, for those competing systems, UPMC's role may be a detriment,” Wanovich said.

Via President Kathy Lokay understands that position, and says she never expected to win a contract with Highmark for physicians who compete with UPMC: “Highmark wants pathways for all oncologists, including non-UPMC physicians. It's understandable that some non-UPMC oncologists might be reluctant to adopt pathways from a competitor,” she said.

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Differing Definitions of ‘Pathway’

But the dynamics of competition are just one reason that Highmark is distancing itself from UPMC/Via. Wanovich says Highmark has never believed in UPMC/Via's definition of a pathway, meaning a single treatment protocol assigned to a specific disease state.

“We need something that allows some flexibility, but still gets at what we believe the end result is, which is that standardization of cancer care can be high-quality, effective, and control costs,” he said.

For UPMC/Via, that has got to sting. Its philosophy is that flexibility in cancer care fuels variability in patient outcomes and drives up the cost of care. In UPMC/Via's view, flexibility is appropriate when oncologists treat patients who have comorbidities or other extenuating circumstances that make a specific pathway inappropriate; in all other cases, adherence to a single pathway is the whole point.

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3-Step Process

According to Lokay, Via Oncology identifies the one best treatment, as supported by the clinical evidence, for about 80% of potential cancer scenarios. Committees of disease-specific experts, including non-UPMC oncologists who have adopted Via Oncology pathways, convene quarterly to review the latest research and define the pathways in a three-step process.

  • Efficacy: If the data show one superior treatment in terms of efficacy, this is Via's pathway.
  • Toxicity: If more than one treatment shows comparable efficacy, the least toxic treatment becomes Via's choice.
  • Cost: If more than one treatment shows comparable efficacy and toxicity, then cost to the patient, payer, and provider are considered with a goal of reducing the cost of care without sacrificing quality or outcomes.
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P4: Accommodate Local Preferences and Give Oncologists Range of Choices

By contrast, P4 Healthcare's approach is to accommodate local preference and give oncologists a range of choices.

“Each time we sign a contract, we identify 12 to 15 regional physicians, and we empower them with the opportunity of creating consensus pathways for their region,” said P4 Founder and CEO Jeffrey Scott, MD. “We do monitor and moderate, but we don't vote. So it really is the physicians' decision.”

Those physicians are not asked to choose a single pathway for a given cancer situation, but rather a few. Dr. Scott said he asks the regional physicians to have the minimum number of pathways needed to cover 90% of patients with each disease state.

P4 works with the insurer to set the required pathways compliance rates. For example, in the first year of P4's contract with Blue Cross and Blue Shield of Tennessee, oncologists must comply with treatment pathways for 70% of their patients and with supportive care pathways for 80% of patients. In the second year of the program, oncologists must have 80% compliance for treatment and supportive care.

Dr. Scott said he thinks a single option for every cancer scenario may actually be more cost-effective than P4's approach—in theory. However, P4 believes it is not possible in many situations to narrow treatment to a single option—and that the single-option approach is too rigid to be adopted across multiple practices and institutions.

“When I go into the marketplace in different regions, I think you have to have some compromise between the most aggressive, single approach, and a more flexible approach so that the buy-in will be greater,” he said.

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Innovent Watching

Innovent Oncology, the third pathways vendor, is watching the Pennsylvania situation from a distance—and with great interest. Roy Beveridge, MD, Executive Vice President and Medical Director of Innovent Oncology's parent, US Oncology, said oncologists might legitimately interpret evidence differently, but regional variation in treatment is not supportable. While each pathways protocol must have flexibility to meet a patient's individual needs, that variation must be based on the science.

“When you start getting down to ‘in Pittsburgh we do it this way, in Baltimore we do it this way, in Miami we do it this way,’ that is not evidence-based medicine,” he said. “That is ‘what are the accepted norms in the treatment of patients in that geographic area?’”

Innovent pathways are being used by oncologists in many markets throughout the nation, Dr. Beveridge said, showing that regional leeway is not needed to gain physician buy-in.

“We have proven that national evidence-based treatment works,” he said.

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What It Means to Oncologists

As of mid-October, Highmark had not signed a contract with P4 Healthcare. If it does, the UPMC/Via pathways can be included in the set of acceptable treatment options so that oncologists in the UPMC system will be in compliance with the P4 program when they use them.

“P4 doesn't dictate what the pathways are, so they don't need to change their practices dramatically,” Wanovich said. “What we need to do is be able to monitor those appropriately, get the right metrics in place that look at cost and quality, and set the right level of reimbursement. That is very consistent with the discussions we were having with UPMC already and the discussions that we want to have with lots of other oncologists in our network.”

Via's Lokay said Highmark representatives will continue to serve on her company's advisory board for pathways.

“There has never been any communication to us about any kind of dissatisfaction with our pathways,” she said.

Those continuing relationships assume that UPMC and Highmark will renew their current 10-year contract, which expires in 2012. Another cancer care trend—moving to hospital-based billing for chemotherapy administration—has caused a schism between the two organizations.

UPMC Cancer Centers, one of the largest cancer care networks in the country, includes Hillman Cancer Center in Pittsburgh and nearly 40 outpatient clinics in western Pennsylvania. About 80 community oncologists and 30 academic oncologists practice in the UPMC system.

Historically, UPMC community oncologists have administered chemotherapy at their office sites, where it is billed as a physician service. However, UPMC is moving to a hospital-based practice model; while chemotherapy will still be administered in offices, it will be billed as a facility-based service. UPMC spokeswoman Wendy Zellner said that UPMC's motivation is to standardize clinical and administrative protocols and procedures.

Of course, chemotherapy administration billed as a facility-based service carries a much higher pay rate, and Highmark has estimated that the billing change will increase its costs by $120 million a year.

“So that's a problem for us in the marketplace,” Wanovich said, pointing out that the increased cost will be passed on to unhappy employers who will have to pay higher premiums to Highmark and to self-insured employers whose claims are administered by Highmark.

Zellner said there has been a lot of misinformation spread on this issue—”UPMC serves the needs of our patients first and simply bills Highmark in accordance with the terms of our contract. This is the way all other providers in the region bill for their service, and the way other [NCI]-designated cancer centers nationwide bill as well.”

With nearly two years before a new contract must go into place, the sniping between the two parties is likely to get louder. But the situation shows how the financial pressures that health systems are experiencing can jeopardize relationships.

Wanovich said UPMC's change in the way it bills for chemotherapy administration did not prompt Highmark's decision to enter into discussions with P4. That said, he did draw a line between the two upheavals in Highmark's relationship with UPMC.

“Even when we try to manage health care costs, we have providers who are seeking the highest level of reimbursement without adding any additional value,” he said. “This does undermine the collaborative spirit of a pathways program.”

© 2010 Lippincott Williams & Wilkins, Inc.
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