The Evolving Role of Cost in Pathways: Cost of Care, Cost Avoidance, and Patient Costs

Sunday’s day of sessions at CPC & CBEx 2023 included a panel on “The Evolving Role of Cost in Pathways: Cost of Care, Cost Avoidance, and Patient Costs,” where participants investigated factors beyond drug costs that affect the bottom line and discussed how pathways can effectively aid in managing these costs. Chevon Rariy, MD, chief health officer and senior vice president of digital health at Oncology Care Partners; Ed Rodgers, director of network development for Elsevier’s ClinicalPath; and Mahek A. Shah, MD, MBA, MS, managing partner at WTM Advisors and associate faculty, Harvard School of Public Health and Brigham Health, former director, teaching faculty of Value Based Care at Harvard Business School, were the panelists, and John E. Hennessy, MBA, principal at Valuate Health Consultancy, served as the moderator. 

Standardization of Care vs Personalized Treatment 

A conversation on how to balance standardization of care with the need to personalize treatment for each patient started the session, with Dr Rariy highlighting the importance of being able to deviate off pathway due to the individuality of patients, who each come with unique backgrounds and circumstances. When thinking about pathways, Dr Rariy explained, it’s important to think about the whole person and their specific needs and goals. “I think we are at the point in which we’re looking at more than just clinical pathways focused on drug pricing . . . or procedures, and we’re really looking at other areas that can influence the entire trajectory of a patient’s care continuum. So whether that’s looking at specific molecular markers that would help to integrate precision medicine and precision treatment for more timely intervention, or if it’s even expanding into what are some of the associated expenses that we can look to manage in a better way.” This includes a broad spectrum of factors, such as hospitalization rate and number of emergency department visits, based on the specific risks of each patient in order to “bend the cost curve around each patient’s journey.” 

Hennessy said there are two elements of “cost” as it relates to care: the first is insurance, including coinsurance, copayments, and deductibles; and the second is the cost of daily living. “We have prescriptions that say, ‘take with food’; rarely do we ask the patient, do you have food?” Hennessy said. Hennessy asked the panelists whether the consideration of the cost of daily living is incorporated into pathways when weighed against the cost of a preferred treatment regimen.  

“I think it depends,” Rodgers said. “It depends on the cancer center, it depends on the resources [the patient has].” Because not everyone has the same access to care, a one-size-fits-all approach to screening and treatment is not sustainable. Rodgers explained that shifting some of the risk from the payer to the provider forces more importance to be placed on the cancer center’s understanding of social determinants of health (SDOH) and how they might factor into a patient’s response to treatment and overall outcome. “If they are taking risk on what that patient’s response to that therapy is going to be, they have some impetus to put in an SDOH-related program and to assess those questions and to act upon them.” 

Patient Costs Beyond Economics 

Rodgers also stressed that patient cost is not simply dollars and cents: “What are ways that we, as a supportive health care community, can limit the traumatic effect of cancer on patients?” Rodgers said the health care community needs to address the mental needs of patients and the latent effects of treatment on patients in real, tangible ways, either through the cancer center or by giving tools to primary care providers to use with their patients. 

Hennessy reiterated that some treatment pathways require a high level of patient support beyond economics, including transportation, childcare, time off work, etc. He posed the question to the panel of how to make this work: Do we build support systems around these patients to help them stay on pathway, or do we ensure that pathways meet patients where they are? 

Real-World Implementation of Pathways

“When we bring pathways into the real world, we want the pathways to work,” Dr Rariy said. “Without providing the supportive services for real-world activities, it’s going to be particularly challenging. And that runs the gamut, in terms of socioeconomic status.” Bridging the gap between clinical data and real-world implementation requires additional resources and services that help the patient stay on pathway. “It’s not a question of can we or should we,” Dr Rariy said. “We have to take these things into consideration, and understand and put resources in place to help patients navigate the system.” 

Dr Shah brought up the challenge of time toxicity. The emotional impact of waiting between treatments, unexpected delays in treatment, etc, is something that is often not discussed with the patient. “It’s much more than just the individual,” he said. “We have to continue to be aggressive around . . . how do we continue to obsess about the patient and what their needs are, what they’re going through in the moment, but then anticipate the needs that are coming up.” 

Financial incentives for providers to stay on pathway create unique challenges around the need for customization and being sensitive to patient needs while also keeping the patient on pathway. Dr Shah agreed that “the pathways and the providers, and the payers, need to balance that personalization with the standardization needed to manage and measure robustly.” To do that requires a base foundation of care standardization on which you can then build personalized and structured layers, including layers that are softer and more personal, not just hard logistics and economics. 

According to Dr Rariy, the key question for achieving this balance is two-fold: How do we truly focus on the patient through patient-reported outcomes, and how do we allow patients to participate in their own care in addition to staying on pathway? Incorporating the personal needs of each patient into their care program allows the clinician to understand out of multiple pathway options what the best combination is for this individual patient. To accomplish this, Dr Rariy continued, we need a robust technology infrastructure at the point of care to assist clinicians with decision-support tools, which allow the provider to take into consideration multiple data points. 

Rodgers shared that at ClinicalPath, individual patient scenarios are built into their pathways to allow for personalization and customization. When a provider wants to go off pathway, they’re presented with NCCN recommendations that provide additional evidence-supported options for treatment. On the topic of payer pathways, Rodgers stated, “We’ve always held . . . that standardization of care is more important—that we are able to measure and demonstrate an adherence to evidence-based care, and a commitment to improved quality and value. What we have never subscribed to is that a Blue Cross/Blue Shield patient should get a different treatment than a United patient.” 

Understanding the patient as a whole, their goals and their specific circumstances, beyond the financial and economic aspects of care, is crucial for involving them in shared decision-making regarding their treatment.