Oncology guidelines and clinical pathways have been on the table for providers and payers for several years. Yet, there is still significant dissonance between providers and payers as to what constitutes “acceptable” guidelines and pathways, and how to monitor compliance in clinical practice.
Clinical guidelines and clinical pathways are most often used to guide treatment planning and practice by providers, and coverage policy and prior authorization by payers. Oncology providers rely heavily on the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines™) and the American Society of Clinical Oncology (ASCO) Clinical Practice Guidelines for treatment guidance.
Oncologists’ and Payers’ Use of Guidelines and Pathways
According to a survey of oncologists and managed care organizations (MCOs) conducted by Genentech in 2016, of the 202 oncologists responding to the survey, overall 53% (n = 107) reported using cancer treatment guidelines, 45% (n = 91) used cancer treatment pathways, and 42% used both guidelines and pathways.1 However, 31% of the surveyed oncologists used neither guidelines nor pathways in their treatment planning, but 18% of them planned to use guidelines and/or pathways in 2017.1
Although it is possible to think that with the increasing attention to accountability and performance-based payments, guidelines and pathways in medical decision-making might have peaked already or are becoming “old school.” However, despite new measures, guidelines and pathways remain important for practicing oncologists. Quality measures are established as checks and balances to ensure that practices do not chase performance dollars at the expense of quality care.
Documentable concordance with clinical guidelines and pathways is essential for practices, especially those participating in the Centers for Medicare & Medicaid Services Oncology Care Model.
Many MCOs follow cancer treatment guidelines and are incorporating oncologists’ use of cancer treatment guidelines into their coverage and reimbursement policies. In the Genentech survey noted above, of the 103 MCOs in this survey, 85 MCOs stated that they follow cancer treatment guidelines to inform their coverage criteria for oncology.1 Of these MCOs, 65% make the use of guidelines by oncologists voluntary, 19% make it voluntary but with incentives given to oncologists who use the guidelines, and 15% of MCOs make guidelines use mandatory, tying oncology reimbursement to the use of the accepted guidelines.1
MCOs incentivize oncologists to follow treatment guidelines primarily through1:
- Reduced prior authorization or precertification requirements
- Share of cost-savings
- Improved or higher evaluation and management fees and drug reimbursement
- Faster processing of prior authorization precertifications
- Per-member monthly fees.
Differences in Guidelines and Pathways
However, there are marked differences between the clinical guidelines and treatment pathways that are recognized by oncologists and those accepted by MCOs for reimbursement purposes. Oncologists and MCOs strongly referenced guidelines from NCCN and ASCO, but it is common for MCOs to translate or refine those guidelines into clinical pathways for use internally or with external vendors.1
Such refinements can create friction between treating oncologists and MCOs and lead to time-consuming and costly communications on both sides related to prior authorizations to justify treatment choices or denials of coverage. Oncology practices can bolster their position with MCOs by referencing reports and formal documentation of their compliance to any guideline or pathway in their clinical decisions. However, a substantial number of oncology centers still do not have the means to provide such documentation.
Hence the increasing importance of clinical guidelines and pathways. Unless a practice has a way to track every clinical treatment choice against some codified clinical guideline or pathway, it may find itself at a disadvantage when challenging a commercial MCO policy or coverage decisions. This will become even more important for those who participate in Medicare’s Oncology Care Model; these practices need to attest to their compliance with clinical guidelines, and will soon be asked by Medicare to prove that attestation when audited.
Tracking Your Choices
What can practices do to track their treatment choices in accordance with a clinical guideline or pathway? The answer may be in the electronic health record (EHR) software you use. Some practices now have arrangements to provide access to embedded clinical guidelines or pathways. Flatiron Health’s OncoEMR EHR software is affiliated with Via Oncology clinical pathways, allowing practices to embed their own guidelines in the clinical decision-making process. McKesson’s iKnowMed EHR system offers the option of a Clear Value Plus support system, which together with the US Oncology Network provides the power of the NCCN Value Pathways.2
In addition, practices can contract on their own with Via Oncology clinical pathways. Recently, ION Solutions of AmerisourceBergen announced a partnership with NCCN to integrate the NCCN Guidelines™ and the NCCN Chemotherapy Order Templates into its IntelliDoseTxM to provide oncologists with point-of-care access to evidence-based treatment decision support.3
In this age of digital technology, practices should not be left without the defense of reports that document their compliance to a clinical guideline or a clinical pathway. If practices cannot provide such documentation and proof, they will continue to be vulnerable to charges of lack of compliance, as well as to increased oversight and management by external entities, such as payers or their oncology management vendors.
The best defense is a strong offense. Compliance with clinical guidelines and pathways will likely never go away as a measure of quality; it is now an essential part of practice operations. Good luck, and put your stake in the ground.
- Genentech. The 2017 Genentech Oncology Trend Report. 9th ed. South San Francisco, CA: Genentech; 2017. www.genentech-forum.com/content/dam/gene/managedcare/forum/pdfs/Oncology-Trends/2017_Genentech_Oncology_Trend_Report.pdf. Accessed August 11, 2017.
- McKesson Specialty Health. McKesson Specialty Health and The US Oncology Network expand agreement with the National Comprehensive Cancer Network, adding new disease states to Value Pathways: expanded agreement enhances Value Pathways, providing physicians access to the most recent evidence available for five additional disease states. Press release. June 14, 2017. www.mckesson.com/about-mckesson/newsroom/press-releases/2017/mckesson-specialty-health-expand-agreement-with-the-national-comprehensive-cancer-network/. Accessed August 15, 2017.
- AmerisourceBergen. NCCN Guidelines and NCCN Templates to be integrated into ION Solutions’ IntelliDoseTxM treatment management module. Press release. July 19, 2017. www.amerisourcebergen.com/abcnew/news/press-releases/nccn-guidelines-and-nccn-templates-to-be-integrated-into-ion-solutions%E2%80%99-intellidosetxm-treatment-management-module.aspx. Accessed August 15, 2017.