A big challenge facing community-based oncology practices as they transition to value-based reimbursement (VBR) models is wide and sometimes unnecessary variation in cancer treatment, which drives up cost without any additional clinical benefit to patients. One of the most effective tools practices can use to overcome this challenge is clinical pathways.
Clinical pathways are evidence-based protocols that help oncologists pick the most appropriate course of treatment for an individual cancer patient. They take into consideration all the different treatment options available and narrow them down into a succinct list of choices that drive the most value, which is simply defined as the best possible outcome at the lowest cost.
Clinical pathways can be developed by individual oncology practices, academic medical centers, cancer research organizations, oncology professional organizations and even health plans. The American Society of Clinical Oncology has published a list of 15 criteria of what ASCO describes as “high-quality clinical pathways in oncology.”¹ Among the criteria at the core of the clinical pathways value proposition are:
- Evidence-based. Are the pathways based on the best available scientific evidence as documented or disseminated in clinical practice guidelines, peer-reviewed journals, scientific meetings, Medicare compendia, Food and Drug Administration (FDA) labeling indications and/or other dissemination vehicles?
- Patient-focused. Do the pathways include evidence-based options to account for differences in patient characteristics and/or preferences (i.e., patient co-morbidities, prior diagnoses and treatments, risks of treatment-related toxicities, treatment schedule and/or financial toxicity)?
- Clinically driven. Is there an established methodology for prioritizing efficacy, safety and cost? How is cost factored into pathway recommendations of therapeutically similar or equivalent treatments?
Three ways clinical pathways benefit cancer patients
There are three primary clinical and financial benefits to patients whose community oncology practices use clinical pathways, including the following:
- Optimized clinical outcomes. Clinical pathways incorporate the latest and most effective treatment options for patients. These may include new immunotherapy drugs, new combinations of existing drugs, new types of radiation therapy, or available clinical trials.
- Minimized clinical toxicity. A clinical pathway will address treatment options and their respective side effects. If two treatment options under consideration have similar efficacy but different side effect profiles, the regimen with the fewer side effects will be the one selected for pathways. Pathways help the oncologist select the treatment that optimizes outcomes and minimizes side effects—both of which are good for the patient undergoing treatment for cancer.
- Reduced financial burden. A clinical pathway takes treatment costs and a patient’s financial situation into account. Some cancers, particularly when in advanced stages, have a poor prognosis. Expensive treatments might not be the best choice. Sometimes treatments offer the same clinical results but at different price points. Choosing a less-expensive treatment that produces the same outcome helps patients lessen or avoid the financial stress of cancer care.
How clinical pathways benefit community oncology practices
Using clinical pathways offer a number of clinical and financial benefits to community oncology practices, including the following:
- Access to the latest medical research. Oncologists want to provide the best available care to their patients, but it’s hard to keep up with the medical breakthroughs in cancer care. New science and new drugs are expanding at an unprecedented rate. Clinical pathways are regularly updated and revised to include the latest available treatment options for patients. They also present clinical trial choices at the point of care. In doing so, oncologists don’t have to try to memorize all the new developments.
- Recognition by payers. As value-based reimbursement models like the Oncology Care Model (OCM) from the Center for Medicare & Medicaid Innovation (CMMI) gain traction, practices whose business models are built strictly on the traditional model of payment for utilization (volume) will fall out of favor with payers. Payers will seek out practices with business models built on value and may direct their beneficiaries to these practices through benefit design or steerage. The use of clinical pathways serves as a basic component of a value-driven business model for community oncology practices, as it balances quality and cost.
- Contract leverage with payers. Oncology practices that follow clinical pathways can use this as a way to collaborate with payers around aligned incentives. For example, a practice might agree to adhere to pathways at a certain rate in exchange for certain concessions, such as no prior authorizations for drugs included in the pathway’s clinical protocols. The payer benefits from lower treatment costs, and the practice benefits from lower operating costs.
- Reduction in drug inventory costs. The use of clinical pathways can reduce a practice’s operating costs in another way: through drug inventory. Rather than ordering and storing the full range of potential medications for patients, practices can order and store only the medications they use most based on their clinical pathways.
- Improved cash flow. The use of clinical pathways can reduce payment denials and payment delays from payers. When a practice follows a pathway agreed to or accepted by a payer, reimbursement for very expensive drugs is rarely declined.
- Readiness for new VBR models. Over the long term, clinical pathways help practices acquire the competencies, culture and technical infrastructure needed to succeed under VBR models like the OCM, the Merit-Based Incentive Payment System (MIPS) and other alternative payment models. Practices that use clinical pathways will put themselves in a strong position as these models spread from Medicare into the commercial insurance sector.
Tactics to promote compliance with clinical pathways
Clinical pathways can generate all of these clinical and financial benefits for patients and practices only if oncologists have real-time access to them, follow a pathway when appropriate, and document their work. A common challenge for community-based oncology practices is ensuring that their individual oncologists consider pathways before they make treatment decisions.
There are a number of tactics practices can deploy to promote pathway consideration by physicians, including the following:
- Technology. Embedding a clinical pathways module in a practice’s EHR system is crucial. As the oncologist enters clinical data into a patient’s medical record during a visit, the EHR system flags a clinical pathway appropriate for the patient’s condition. The system prompts the physician to use the pathway and enables the oncologist to have the best and most current treatment information at the point of care, ready to discuss with the patient. When a physician goes “off pathway,” or chooses not to follow a clinical pathway for legitimate medical reasons, the EHR system will ask the oncologist to select and document the reasons for doing so.
- Clinical pathways committee. A standing clinical pathways committee within a practice can review clinical and financial results, pathway exceptions and compliance by individual oncologists. A practice can choose if they want to develop their own set of pathways or use an existing product. If the practice chooses to build their own, then a committee will need to be in place to ensure the practice’s pathways are up-to-date and available to all at the point of care. Reviewing results reinforces benefits and drives further performance improvement. And reviewing compliance by individual physicians can flag outliers for process and quality improvement.
- Training and education. Not all physicians are adept at using EHRs and modules within EHRs for clinical decision support. Practices should teach oncologists how to use digital tools at the point of care to make the optimum treatment choices. Improving their user experience will improve compliance and documentation and, hopefully, enrollment in clinical trials with the benefits accruing to the practice and cancer patients.
In the current scientific and health care environment, an oncologist wants to treat his or her patients with the regimen that delivers the best outcome, lowest toxicity profile and at the lowest possible cost. It would seem to be the obvious thing to do every time for every patient, but without clinical pathways guiding decision-making, this can be difficult to accomplish.
Related: Learn more about Studiomaca’s value pathways solutions for oncology practices