Clinical Pathways Slow Drug Spending in Community Oncology

Roxanne Nelson, RN, BSN

June 12, 2020

The use of high-value clinical pathways combined with regular, data-driven peer discussions can slow drug costs in community oncology practice, according to new findings.

Cancer Care Specialists of Illinois (CCSI) selected New Century Health, a developer of value-based clinical pathways, to help them capture episode-based savings working within the Oncology Care Model, a federal initiative.

From the first quarter of 2017 to quarter 1 of 2019, the median drug spend increased less rapidly for CCSI (18.6%) compared with OCM (34.4%). Furthermore, the percentage difference in drug spend for CCSI relative to OCM decreased from 13.5% to 0.1% (P < .001).

Additional analyses found that, over a 15-month period (October 2017 through December 2019), CCSI achieved an increase in pathway adherence from 69% to 81%.

The results were published March 20 in the Journal of Oncology Practice.

Andrew Hertler, MD, chief medical officer at New Century Health and lead author of the article, pointed out that a number of clinical pathway tools are available to practices. "However, clinical pathways alone are not enough to reduce costs in a financially sustainable way, particularly when the practice may be reliant on volume-based drug spreads for revenues," he said. "The greatest pathway won't work if doctors don't use it, so you need the incentive or payment program to offer a financial benefit to providers for following the pathways."

He emphasized that engagement is needed with physicians on a clinical level, so they are fully involved in discussing and deploying the pathways. "And you need to present good data and benchmarking to reinforce the new habits the practice develops," Hertler said. "If you can put that in place, other community oncology practices should have similar opportunities to reduce their reliance on drug spread for revenues and instead adopt more value-based drug prescribing protocols."

Commenting on the article, Vinay Prasad, MD, MPH, an associate professor in the Department of Epidemiology and Biostatistics at the University of California, San Francisco, noted that the "paper is great but also sobering."

"It looks like their intervention did not lower spending, but slowed the rate of rise," he said. "There are so many new cancer drugs and old drugs that keep having their price raised that our best efforts might only slow the rate of rise."

Multistep Process

The Oncology Care Model (OCM) was rolled out in July 2016 by the Centers for Medicare & Medicaid Services (CMS), with the goal of providing higher-quality care while at the same time lowering cost.

Participation in the OCM pays providers the standard fee-for-service reimbursement and an additional $160 per month per patient for enhanced care coordination. In addition, if requisite quality thresholds are met and aggregate payments fall below the target, OCM practices receive a performance-based payment.

CCSI, an OCM participant, is a community-based oncology private practice with offices in rural Illinois, and has a staff of 14 medical oncologists, four mid-level providers, six radiation oncologists, and one urologic oncologist. New Century Health was engaged by CCSI to provide support and resources to help maximize its OCM episodic cost savings. The association began in January 2017, and the pathway program officially launched later that year.

The two largest expenditures were drugs — which made up the majority of costs — and hospital admissions. "Drug cost was the biggest factor and we looked at ways we could reduce that spend," said Mark Walshauser, MD, a medical oncologist/hematologist at CCSI.

The first step was to integrate New Century Health care pathways, and these were embedded in all CCSI physician computers for rapid access and as a reference for decision-making. Additionally, treatment plans were submitted in real time to New Century Health to measure adherence to the pathways.

Access to the pathways was made very user friendly. "We got an app that allows for one-click access to the clinical pathways," Walshauser told Medscape Medical News. "And within two or three clicks, it will get you to what you are specifically looking for, like if you are trying to look up the most effective treatment and cost for pancreatic cancer."

The next step was for the CCSI physicians and New Century Health to meet biweekly to review treatment plans, adherence to the clinical pathways, and drug use, and explore opportunities to reduce costs without sacrificing quality of care.

"We reviewed any time a physician went off pathway, which can happen for any number of reasons, and that was an opportunity to improve care," he said. "For instance, if they used X drug, we could point out that Y works just as well and is less expensive."

One way of reducing drugs costs was to replace branded drugs with biosimilars. "We were early adopters of biosimilars," said Walshauser, "and that was a third step in the process."

Biosimilars are rapidly coming out of the pipeline, and in some cases, they are priced anywhere from 50% to 70% less than the branded drug. The good news is that some drugs now have more than one biosimilar, and the companies are competing with each other for market share.

"They are coming in at lower prices, and it's almost a race to the bottom," Walshauser pointed out. "They also become discounted over time."

Cutting OCM Spending

During the study period (from quarter 1 of 2017 to quarter 1 of 2019), the drug spend values for CCSI and OCM median were compared.

The median drug spend per patient increased more slowly for CCSI as compared with OCM median across the study period. It increased 18.6%, from $2661 in quarter 1 of 2017 to $3156 in quarter 1 of 2019. However, for OCM, the median drug spend increased by 34.4%, from $2345 in quarter 1 of 2017 to $3151 in quarter 1 of 2019.

Walshauser cautioned that this process takes time. "We didn't do all of this the first week," he said. "These changes can't be made overnight — it has taken us 5 years, and we didn't have any savings during the first year."

He also recommends that physicians in a busy practice can benefit from working with a vendor like New Century Health, in that the vendor can help make the process a smooth one.

Pervasive Financial Conflicts

UCSF's Prasad feels that the model in the study can be extended to other practices, and that pathways can become even better at optimizing high value care. "Encouraging doctors to make wiser choices will benefit patients and society and has potential to someday lower costs," he said. "I believe physicians are good people and want to do the right thing."

However, Prasad emphasized that to "really break the addiction to unproven, costly, marginal cancer care, we need to also chip away at the pervasive financial conflicts between companies and doctors, and we need to offer CME [continuing medical education] that is not heavily indebted to funding from pharmaceutical companies, and CME that promotes patients' best interests."

Hertler is an employee of New Century Health. Walshauser is employed by Cancer Care Specialists of Illinois. Prasad has disclosed research funding from Arnold Ventures; royalties from Johns Hopkins Press and Medscape; honoraria from Grand Rounds; lectures from universities, medical centers, nonprofits, and professional societies; consulting from United HealthCare; speaking fees from Evicore; and a Plenary Session podcast with Patreon backers.

JCO Oncology Practice. Published online March 20, 2020. Full text

For more from Medscape Oncology, join us on Twitter and Facebook


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: