Clinical Pathways Programs Can Reduce Costs in Oncology

Roxanne Nelson

August 07, 2013

Evidence-based clinical pathways might be able to reduce overall spending on cancer care without compromising quality.

According to a new study, an oncology pathways program could save about 15% on cancer-related costs and reduce hospital admissions by about 7%.

The results, first presented during a poster session at this year's annual meeting of the American Society of Clinical Oncologists (ASCO) (abstract 6553), were published in the May/June issue of Evidence-Based Oncology, which is a supplement to the American Journal of Managed Care.

The scheme was devised by Cardinal Health, a Fortune 500 healthcare services company that specializes in the distribution of pharmaceuticals and medical products. In partnership with payers, they establish evidence-based oncology treatment pathways to eliminate unnecessary medical interventions and promote the most cost-effective treatments to enhance care and reduce costs. In August 2008, Cardinal Health Specialty Solutions partnered with CareFirst BlueCross BlueShield (CFBCBS) to launch the first cancer clinical pathway in the United States.

"Only recently have we had enough experience, analysis, and data to subject our work to validation and peer review," said Bruce Feinberg, MD, chief medical officer of oncology at Cardinal Health Specialty Solutions.

To be successful, physicians will have to walk the walk, not just talk the talk.

We believe that, unlike the limited body of work that precedes this research, we have demonstrated scalability across diverse networks of providers and think that our approach to clinical pathways can accomplish the trifecta of improved outcomes for all 3 critical stakeholders — patients, physicians, and payers," he told Medscape Medical News.

To be successful, "physicians will have to walk the walk, not just talk the talk," he noted, adding that they can't just "merely say they follow National Comprehensive Cancer Network guidelines."

Cost Savings

More than $8 million in cost savings have already been reported. The objective of this study was to obtain third-party validation of the observed savings of the pathways program.

Dr. Feinberg and colleagues reviewed CFBCBS claims data from 2007 to 2010. They identified 2424 patients with breast, colon, or lung cancer who were treated by physicians participating in the pathways program. In addition, they retrospectively identified 1490 people who were treated by physicians outside the CFBCBS network to serve as the control group.

A third-party actuary/analytic team validated the observed savings and financial impact of the pathways program.

The primary outcome was the sum of allowed cancer costs for 270 days after a patient's first chemotherapy treatment. Cancer-related costs in the pathways group were more than 15% less than those in the control group.

A secondary outcome was the probability of an inpatient admission over the same time period. Hospital admission was 7% lower in the pathways group than in the control group.

The variety of drug combinations was also analyzed. Although both groups experienced a reduction in variability, it was greater in the pathways group.

Factors Critical to Success

Along with improved collaboration and communication among participating physicians, several other factors were critical to the program's success, Dr. Feinberg explained.

"Physicians within the CareFirst network developed the clinical pathways they followed," he told Medscape Medical News. "They were not simply handed a 'recipe book' to follow. We believe this physician involvement is critical to physician buy in and support."

Another factor is the "alignment" of incentives and physician rewards. "We worked with CareFirst to reprice generic medications to create margin neutrality with equally effective brand regimens," he said. "This is a critical step when it comes to leveling the playing field among therapeutic options."

Physicians were also rewarded for their participation and compliance.

Dr. Feinberg added that they were "really focused on addressing the overarching fundamentals of care that impact both quality and costs." As an example, he cited the use of single-agent sequential therapy in late-line disease, which is far more important than creating preferred therapy lists.

"Last, I wouldn't diminish the importance of a third-party facilitator to serve as an honest and agnostic broker between the payor and physician," he noted, pointing out that these 2 parties have been historically viewed as adversaries.

"We were able to play that role, which I believe is a critical factor in fostering the collaboration necessary for this program's success," Dr. Feinberg said. "In the end, success is about changing entrenched behaviors, which is far more complicated than revising formularies."

Clinical pathways programs are already in use by individual practices, state oncology societies, and integrated delivery networks, he explained, and the team is working with other payors to implement similar programs. In all cases, the success of the program can only be validated if data are collected, analytics are performed, and outcomes are reported.

"I don't think it's likely that this model would work simply by providing physicians with established clinical pathways," he emphasized. "Other factors are critical to clinical pathways success, such as aligned incentives, physician rewards for participation and compliance, and coordination by a trusted agnostic outside entity."

Results in a Microcosm

Gary H. Lyman, MD, MPH, who was asked by Medscape Medical News to comment, noted that this study "presents results, in a microcosm, that many of us working in the guidelines space hope and expect will play out on a larger scale."

"While the appropriate use of evidence-based guidelines and pathways makes intuitive sense, until recently, the only evidence of utilization has been how frequently they are accessed," said Dr. Lyman, who is a professor of medicine and director of the comparative effectiveness and outcomes research program at the Duke University School of Medicine, Durham, North Carolina. "With quality-improvement programs, including ASCO's Quality Oncology Practice Initiative, we now have guideline recommendation criteria by which practices can benchmark themselves with their peers, as well as look at improvement over time."

However, he pointed out that there is still a lack of evidence showing the impact of guidelines and their use on clinical practice and patient outcomes.

"One important outcome that has been recently demonstrated and further validated in this study relates to the impact of guidelines or pathways on healthcare costs," Dr. Lyman told Medscape Medical News.

However, there are many limitations to this study, including its observational design and the retrospectively identified control group, he noted. In addition, whether the physician or payer settings studied here are representative of broader oncology practice in the United States needs to be evaluated, he said.

"These data are not based solely on academic settings or patients eligible for clinical trials, and thus represent, to some extent, a more real-world setting," Dr. Lyman said. "While it is likely that comprehensive evidence-based clinical practice guidelines will have an impact on physician decision-making and improve the quality of patient care, further study of long-term clinical and economic outcomes in other practice and payer settings is important."

This study received no outside funding. The authors have disclosed no relevant financial relationships.

Am J Manag Care. 2013;19(Special issue 4):SP153. Abstract


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