Increased spending on cancer care can be attributed to a number of contributing factors, including an aging population, earlier diagnoses, and longer survival rates. Medical advancements in surgeries, radiation therapies, and medications—including advanced immunotherapies and targeted therapeutics—contribute to increased spending as well, as these advancements parallel rising treatment costs.
Clinical pathways have been brought to the forefront as a key component to success in a value-based care environment. The question is, how is your organization utilizing pathways to their fullest in order to realize the most benefit?
Recently endorsed by the American Society of Clinical Oncology (ASCO), the Clinical Pathways Congress (CPC), now in its third year, attracts nearly 300 stakeholders throughout the health care spectrum, including cancer center directors, clinical pathway directors, medical and pharmacy benefit managers, pathway vendors, and payers. CPC 2018 will focus on the practical, taking a deep dive to address the operational questions raised by pathway stakeholders who will have the opportunity to connect with experts and gain readily usable and cost-effective solutions to achieve optimal patient care.
The Congress will be steered by leading pathway experts such as Robin T Zon, MD, FACP, FASCO, chair of the ASCO pathways taskforce, and Aymen Elfiky, MD, MSc, MBA, chief of the oncology and hematology division and director of analytics at The Brooklyn Hospital Center. Barbara L McAneny, MD, MACP, FASCO, president of the American Medical Association (AMA), will be giving the keynote speech, sharing her insights as one of the earliest adopters of clinical pathways. She will also outline her plans to help extend more value-based approaches to other areas of medicine as AMA president.
To highlight some of the exciting sessions happening at CPC 2018, Journal of Clinical Pathways (JCP) spoke briefly with a few of the presenters to get a sneak peek at what attendees can expect to learn at the Congress.
Buy or Build? The Pros and Cons of Vendor- and Provider-Developed Pathways With Insights From the ASCO Oncology Pathway Program Assessment
Robin T Zon, MD, FACP, FASCO
JCP: Which type of pathways, vendor- or provider-developed pathways, are more prevalent in the field, and what do you think are the contributing causes for this? How do you project the future landscape of pathway development will shift?
Dr Zon: It is impossible to know how many pathways there are out there, as provider-developed programs are not publicly disclosed. For example, a private practice may have their own pathways or regions may have them. At this point in time, there is no requirement for a pathway program to be registered in a database, and I suspect that will not occur unless a deeming or certification process is developed—even then, only the pathways that are deemed or certified would likely be known. We do know there is heterogeneity in pathways based on who is developing them and how they may or may not stand against the ASCO High Quality Criteria.
JCP: Can you expand on the value of the data supplement in the appendix of the ASCO’s pathway vendor assessment report? In what ways can providers utilize this resource?
Integration of Genomics Into Clinical Pathways
Andrew Hertler, MD, FACP
JCP: Can you explain the relationship of precision medicine to clinical pathways? How will the continued defining of tumors by specific genetic mutations influence this relationship?
Dr Hertler: Precision medicine is an emerging approach for disease management that takes into account individual variability in genes, comorbidities, environment, and lifestyle as opposed to a “one-size-fits-all” approach in which disease management strategies are developed for the “average” person. Prospective clinical sequencing of tumors has emerged as a mainstay in cancer care with more than 3000 unique somatic mutations, fusions, and copy number alterations identified in over 400 cancer-associated genes. This clinical complexity is greater than an individual physician’s capacity to keep at “top-of-mind.” Clinical pathways are becoming an essential tool to manage this increased clinical complexity in a value-based care delivery landscape.
JCP: In what ways do clinical pathways need to evolve in design and in implementation in order to incorporate genomics?
Dr Hertler: To incorporate genomics, sufficient granularity will need to be built into pathways to allow for the variations in care required to manage the increasing number of actionable somatic mutations. It is possible that some pathways may need to be triggered by individual mutations as opposed to the tumor type. The pathway tools developed will need to be simple and efficient to use in order to provide decision support to the physician at the point of care.
Real-World Experiences Developing, Implementing, and Evaluating Clinical Pathway Programs: Part I
Linda Bosserman, MD, FASCO, FACP
JCP: What are some issues you wish you would have considered, or conversations you wish you had had, before choosing and implementing a pathways program?
Dr Bosserman: We had pretty detailed evaluations of available systems before we chose a pathway system in October 2016 and went live January 2017. A challenge is knowing what else is on the horizon. After we made our best choice at the time, another system the following year was able to integrate more payer pathways and automate authorizations for pathway choices within their stand-alone pathway system.
Knowing why you want to implement a pathway system will help you choose one, but the details primarily impact the medical oncologist; so that fact is important to keep in mind.
JCP: What are 2 of the biggest challenges you have faced when executing clinical pathways programs? How did you overcome them?
Dr Bosserman: The major challenge is the lack of integration with our Epic electronic health record (EHR); we have to use the icon, enter required staging to activate a pathway, then go back to Epic. We need full staging in Epic for our enterprise needs. With the 2018 Epic upgrade, there are plans to enable staging from Epic to be pulled into our Via Pathways, allow pathway selection, then take the user back to the Epic Beacon module order protocol/pathway selected. This will be another year, meanwhile docs are trying to balance more demanding patient care with decision support documentation and ordering and enterprise data entry needs.
How Do We Measure Whether Pathways Are Working? Defining Successful Outcomes and Demonstrating ROI of Clinical Pathways
Ray Page, DO, PhD, FACOI
JCP: What kinds of costs—expected and unexpected—arise when clinical pathways are implemented in a facility or health system?
Dr Page: Expected costs can be highly variable, depending on staff size, location, practice environment, and vendor relationships, but it can range anywhere between $3000 to $10,000 per full-time equivalent physician per year. There may be a few institutions that develop their own internal pathways systems, in which physician time for evidence-based development and timely updates and maintenance, information technology (IT) costs, legal costs, and administrative staff costs can likewise be substantial. Unexpected costs would include IT costs, EHR vendor costs with interphases, and negative staff productivity costs if the pathways system is not fully efficient and integrated.
JCP: What are the multiple aspects of clinical pathways return on investment (ROI), which you will be expanding on in your presentation? What tools are necessary to extract the data to measure these areas?
Dr Page: Typically, ROI is calculated in terms of financial gain beyond the original investment over a defined time period; however, the ROI of oncology clinical pathways (OCPs), in principle, should extend beyond financial consideration and be calculated in terms of patient-centered ROI. Stated differently, OCPs may have extra financial value that is not ordinarily reflected in conventional financial accounting statements.
The opportunity for tremendous benefits occurs through impacting quality standards and metrics, by improving performance, efficient use of resources, and reductions in costs for pharmacy benefit plan returns. This translates into better patient outcomes, which, in turn, favorably impact practices financially under new value-driven payments that come from the Merit-Based Incentive Payment System and the Oncology Care Model. In this context, resources should include items such as durable medical equipment, drugs, and diagnostics, but also the management and appropriate maximization of medical knowledge, practice administrative activities, and provider time and energy.
Currently, a robust OCP system has the capacity to provide the basics for benchmarks and analytics related to costs. It is the only way to determine costs of care related to risk contracts. Monthly reporting of pathways adherence, compliance, and outcomes allows for payer contract negotiations for such things and preauthorization exemptions, reduction of peer-to-peer reviews, elimination of step edits, and optimization of institutional formulary preferences. Pathways also allows for an easier mechanism to find lost charges because of standardized protocols.
What ROI has thus far been realized? There are some reports in the literature and presentations of data not yet published in peer-reviewed journals that suggest that the ROI of OCP inclusion in patient management and payment models has optimized patient outcomes, with a decrease in emergency room visits and hospitalizations, thereby reducing costs substantially. Other benefits include improvement in quality-of-life measures, optimized practice efficiencies, and reduced administrative costs/resources from the improvement of patient flow efficiencies, chair time management, triage nurse efficiencies, and precertification processes. In general, most of the data managed in a pathways system comes from granular data fields, therefore, extraction of pertinent clinical data, staging, lines of therapy, regimen details, responses, and treatment outcomes is generally easy and reliable.
