Chicago, IL—Developed in the early 2000s, clinical pathways are being increasingly used by providers. According to ASCO’s The State of Cancer Care in America, 2016 report, there was a 46% increase in the provider use of clinical pathways between 2014 and 2015, and that figure now exceeds 50%, reported Robin Zon, MD, FACP, FASCO, Medical Oncologist, Michiana Hematology Oncology Advanced Centers for Cancer Care, South Bend, IN, and Chair of the ASCO Task Force on Clinical Pathways, at the 2017 ASCO annual meeting. Dr Zon described the potential role of high-quality clinical pathways in payment reform and utilization management and forecasted the future of clinical pathways, with possible returns on investment.
“Pathways are agents of change and transformation away from a provider-centric, value-based reimbursement system to a value-based, patient-centric system,” said Dr Zon. “At the end of the day, we’d like to be much more exact and precise than we currently are in guaranteeing that a recommended intervention is going to work. Pathways will be one of the tools that will eventually revolutionize care.”
Changing Prescribing Habits
Whereas guidelines frequently offer multiple recommendations for a specific condition, clinical pathways delineate a single best treatment or intervention, detailing the essential steps that are needed in the care of patients, she said. Whether nationally or regionally developed clinical pathway programs, the number of providers using clinical pathways is growing every day and is already influencing physician prescribing behavior.
After a cost comparison demonstrated an approximate 14% monthly cost advantage for panitumumab (Vectibix) over cetuximab (Erbitux), despite equivalent efficacy and toxicity, the University of Pittsburgh and Indiana University initiated a substitution of panitumumab for cetuximab in their clinical pathways.
“This shows the power of clinical pathways to rapidly change prescribing habits, and by extension of analysis, we can estimate that there was also a significant reduction in cost and savings,” Dr Zon explained.
Clinical pathways can also potentially protect patients. A retrospective cohort study of 981,729 women with breast cancer from 2004 to 2013 showed that the appropriate receipt of adjuvant endocrine therapy varied significantly by age, race, geographic location, and receptor status—up to a 13% difference in treatment recommendation.
“I was shocked by these results,” said Dr Zon, who noted that clinical pathways can potentially protect patients from “undertreatment, overtreatment, and mistreatment.”
Reimbursement
Clinical pathways are evolving as a cornerstone of future reimbursement methodologies and quality efforts, she said. Clinical pathways can help providers reduce administrative burdens by avoiding time-consuming prior authorization and appeals with payers. They are also a great tool to capture stage and molecular data for a more refined risk adjustment, “which is extremely important in today’s world of reimbursement with Medicare and Quality Payment Program,” explained Dr Zon.
Meanwhile, payers are incentivizing oncologists to use clinical pathways by offering increasing reimbursement, care management fees, and shared savings. Some payers are even beginning to waive prior authorization for on-pathway treatments, bestowing preferred provider status and providing expedited claims processing.
High-quality clinical pathways can also be leveraged to measure Resource Use in the Merit-Based Incentive Payment System for the Centers for Medicare & Medicaid Services.
“We know that we cannot control the cost of drugs or interventions, but we want to deliver the right care at the right time for the right patient. I suggest that pathways are a feasible alternative to episodes of care and can perhaps replace [Medicare] Part B drugs in terms of calculations, because they can help determine whether a provider adhered to a clinically appropriate course of care,” she explained.
Return on Investment
Given the high cost of developing or purchasing a clinical pathway program, return on investment for clinical pathway utilization is a common concern. Although the most important return on investment is optimizing patient outcomes, clinical pathways may also maximize the value of the dollar spent in the healthcare system.
Clinical pathways can be important in helping providers integrate a “wealth of information,” assuring that the most recent scientific and real-world evidence is the basis for intervention selections. However, strategies are needed to maximize the return on investment, said Dr Zon.
Patient Outcomes
Clinical pathway analysis should demonstrate that quality of care and patient outcomes are improved, while considering financial perspectives of patients and payers.
“Ultimately, patients are the target of everything we’re doing, and they’re very concerned about the use of guidelines and pathways in rationing care. If pathways are to be an integral part of patient-centric, value-based care, this will require education, information, and transparency,” concluded Dr Zon.