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Are oncology pathways effective? AMCP presenters weigh in


Faced with a proliferation of oncology treatments, payers have started using oncology pathways. But what do these programs look like, and are they really working?

Faced with a proliferation of oncology treatments, payers have started using oncology pathways. But what do these programs really look like, and are they really working?

During the October 5 session, “Emerging Lessons from Oncology Treatment Decision-Making Programs” at the Academy of Managed Care Pharmacy (AMCP) Nexus in National Harbor, Maryland, presenters sought to answer these questions.

Stern“We certainly see a lack of treatment coordination between the various providers-hospitals, physician, outpatient, radiology, etc.,” said presenter Debra J. Stern, RPh, senior vice president of strategy and business development at eviCore Healthcare, a medical benefits management solutions provider. “There’s non-evidence-based treatments being used, and the incentives we have really are not aligned to patient care.”

Stern, who presented with Lee N. Newcomer, MD, MHA, senior vice president of UnitedHealthcare Oncology and Genetics, and Ann N. Nguyen, PharmD, director of oncology solutions at Anthem Inc., added that the industry is in a period of “tremendous experimentation” on how to measure the value of therapy and reimburse providers appropriately.

Clinical pathways

To define clinical pathways, Stern referred to the American Society of Clinical Oncology Policy Statement on Clinical Pathways in Oncology, which states that oncology pathways are evidence-based treatment protocols for delivering quality cancer care. These pathways balance the considerations of:

  • clinical efficacy;

  • safety;

  • toxicities;

  • cost; and

  • scientific advances.

The percentage of plans using clinical pathways grew from 21% in 2014 to 38% in 2015, said Stern. She stressed that pathways must demonstrate “value” (improve quality and reduce costs).

UnitedHealthcare’s approach

NewcomerNewcomer, of UnitedHealthcare, pointed to two approaches the payer is using to encourage pathways: the episode payment approach and the online precertification approach (which he referred to as “online decision support”).

In the episode payment approach a medical group chooses their pathways for a particular episode of cancer patient care (breast, colon, or lung cancer) and they receive financial gains if they lower total costs of care below what would be paid fee-for-service for the episode, or improve survival, said Newcomer.

For more on the methods used to determine payment, click here.

UnitedHealthcare first implemented the program between October 2009 and December 2012 in a pilot study. That study produced a significant reduction in hospitalizations for patients and a 34% reduction in total costs while improving quality, according to an October 2015 statement from the payer. That statement also indicated that the total number of participating oncologists was 650 in seven states.

The online precertification approach, ensures compliance with guidelines, not pathways, and it is a digital tool that offers all National Comprehensive Cancer Network (NCCN) recommended options to physicians, said Newcomer, noting that the payer has used NCCN as the standard for coverage for several years.

Despite repeated communications, however, UnitedHealthcare found that providers sometimes forgot about the NCCN guidelines, and were giving drugs that weren’t appropriate, and therefore, weren’t receiving reimbursement, said Newcomer. In fact, the payer was denying 7% of chemotherapy drug claims retrospectively.

So, it began offering a digital NCCN guideline tool to providers. The tool automatically populates the NCCN-recommended treatments based on a patient’s specific clinical condition. Once a physician confirms the treatment is consistent with NCCN Guidelines, UnitedHealthcare issues an immediate coverage approval.

Now, Newcomer said, physicians are getting immediate approvals in 70% of cases in less than five minutes. And, 99% of those that don’t get immediate approvals get an answer from a medical oncologist in less than 24 hours. The noncertification rate is 1.7%.

Next: Anthem's approach



Anthem’s approach

NguyenAnthem’s pathway program is structured around three key pillars: quality, delivery, and affordability, said Nguyen.

The program has a prospective payment model, it is voluntary (all providers who treat cancer patients are eligible), and it provides enhanced reimbursement for care coordination and treatment planning when a participant selects an Anthem-approved cancer pathway.

That enhanced reimbursement is $350 per member per month on active treatment (drug treatment), said Nguyen. 

The program now includes 17 cancer or tumor types, said Nguyen, noting that the program is very similar to Medicare’s Oncology Care Model (OCM) initiated this year.

“We were a little bit ahead of the curve in thinking about this space,” said Nguyen. “We’re very excited that there’s tremendous alignment with OCM with many of the key principles of the program.”

There are more than 8,000 providers participating in the program, and currently 6,000 cases are treated per month, she said.

A poster presentation at the ASCO Annual Meeting in June 2015 noted that, among registered patients, pathway adherence was 63% for breast cancer, 72% for colon cancer, and 63% for non-small cell lung cancer.

The goal is to grow pathway adherence to 80% over four years, said Nguyen.

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