Better Outcomes, Decreased Costs with Oncology Clinical Pathways

by Don Jewler, Director of Communications, ACCC

REPORT FROM PHILADELPHIA
Payment models in oncology are changing fast, driven by the high costs of oncology drugs, comparative effectiveness research findings, and variations in care. The 100 cancer care providers who gathered for ACCC’s seminar in Philadelphia were treated to an in-depth exploration of today’s shifting landscape in oncology reimbursement as well as the opportunities that new arrangements with insurers may offer.

The transformation will affect patients as well as providers. “We’re seeing pretty profound changes in benefit design,” said Donald Liss, MD, vice president for clinical programs and policy for Independence Blue Cross, the largest health insurer and managed care organization in the Philadelphia region. “High-deductible plans with employee-controlled spending accounts, consumer-directed health plans with high deductibles, narrow networks and increases in consumer cost sharings for health benefits.”

Employees contribute 45 percent more to their health plans than they did five years ago. From 2010 to 2011 the average employee annual premium payment increased 11.8 percent.

Providers will see increased use of bundled payments for a year’s worth of oncology care, for example, decoupling payments for drug and provider payment, more attention to precertification and accuracy in claims payment, and the promotion of adherence to accepted guidelines. Independence Blue Cross (IBC) “struggles with that,” Dr. Liss said of cancer management systems that integrate pathways into daily workflow. IBC receives “pitches” from a number of cancer management system companies to put a pathway program in place. “We look at these…We ask what are the consequences versus the benefits,” Liss said.

Why is cancer management needed? Costly drugs, for one.

“Looking forward to 2013, oncology is one of the seven therapeutic areas likely to drive the majority of drug spend 2011-2013,” said Amy L. Schroeder, RPh, senior consultant at DK Pierce & Associates, Inc.

She also cited variations in care as driving the transformation in oncology payment systems. “The use of chemotherapy in the last two weeks of life overall, for example, was about 6 percent of patients, but in some regions and academic medical centers the rate exceeded 10 percent. The use of hospice care varied markedly across regions and hospitals,” she said.

Comparative effectiveness research findings are also playing a part in payment model changes, said Amy Schroeder. The majority of employers expect CER findings to be used by their insurers.

Increasingly, commercial payers are finding value in clinical pathways. Most of the top insurers are initiating pathway approaches, focusing first on breast, colon, lung, and prostate pathways, said Amy Schroeder. Lymphomas, ovarian, and multiple myeloma are targets for expanded pathways in 2012.

Making decisions based on a clinical pathways program works well for Ray Page, DO, PhD, president and director of research at The Center for Cancer and Blood Disorders in Fort Worth, Tex. “Clinical pathways allow doctors to be more efficient in our practice. We are more predictable in our drug buys,” he said during a panel discussion.” The system also enhances his research program.

Panel participant Bruce Feinberg, MA, BS, MD, medical oncologist and vice president, CardinalHealth/P4 Pathways, used clinical pathways in his practice back in 1991, developed with a recognition that consensus would drive quality and that oncology is a complicated system. “Variance drives up costs of care, puts patients at risk. Clinical pathways can accomplish better outcomes…and decrease cost of care. That’s my experience,” he said.

Okay, so clinical pathways offer lots of benefits and provide direction in selecting appropriate care.

How can they best be integrated into provider business or web-based access?

Check back for the next blog.