In response to the billions of dollars wasted each year in the United States on fragmented, ineffective, and uncoordinated care, some healthcare reform efforts have focused on integrating the delivery of healthcare.

 Today, millions of Americans receive their healthcare from integrated delivery networks (IDNs).

However, just what is an IDN? Today, there really is no single answer.

 “The phrase covers a spectrum of scenarios; it has not been defined and is actually used as a catchall phrase to cover a variety of types of healthcare arrangements,” explained health economist Mark Hornbrook, PhD, researcher with the Cancer Research Network and senior investigator and chief scientist at the Kaiser Permanente Center for Health Research in Portland, Oregon. Integration might take place vertically, across different levels of care, or horizontally, such as occurs with hospital mergers.

In practice, an IDN might coordinate and standardize clinical care, disease management, financial management, and human resources across all of its providers and facilities. Some IDNs develop and employ patient care strategies with the end goals of cost-effective improvements in health outcomes, quality of care, and efficiency.

 Evidence demonstrates that patient care strategies are more likely to be used by IDNs than solo practitioners.

According to the 2012-2013 National Committee for Quality Assurance (NCQA) private health insurance plan rankings, half of the nation’s top 10 ranked plans (N = 474) are IDNs that provide insurance and employ the doctors who serve their clients.

 The rankings were published in the November 2012 issue of Consumer Reports, which states,“Unlike traditional, independent fee-for-service doctors and hospitals that make money by doing as many treatments and procedures as possible, whether needed or not, integrated plans prosper by keeping their customers healthy and avoiding wasteful care.”

		Figure 1. Total Medical and Pharmacy Costs (per Patient per Month) for Patients With or Without Cancer

		Source: Reprinted with permission from Kolodziej M, Hoverman R, Garey JS, et al. Benchmarks for value in cancer care: an analysis of a large commercial population. J Oncol Pract. 2011;7:301-306.

In the United States, substandard, heterogeneous, and excessive cancer care adversely affects a number of important short- and long-term outcomes including survival, quality of life, and cost.

 The complex and multidisciplinary nature of cancer care makes it prone to system failures, such as inadequate hand-offs, poor communication, and lack of accountability between providers. 

 Additionally, the cost of cancer treatments— especially medical oncology and specialty pharmacy drugs&mdash;is notoriously high. Hence, strategies to promote their cost-effective use have become key elements of cost-reduction efforts (

In the 2012 market intelligence report, Academic Cancer Centers: Trends Impacting Key Account Management, Inside Oncology, LLC, predicted that by 2016, the majority of patients with cancer will be treated at IDNs and cancer institutions (

 Factors contributing to this trend include Medicare reimbursement rate reductions for community practices, loosened 340B drug pricing qualification criteria, and pressure to meet new quality and performance requirements of the Centers for Medicare & Medicaid Services (CMS).

 “CMS has put in quality programs that are really stimulating and motivating people to become more aware of quality of care and integrating care,” stated David Guy, managing partner at Inside Oncology.

Well-established cancer centers have been delivering integrated cancer care for years. Most of them offer patient care teams comprising a range of specialists, as well as a breadth of services at a single location. In this setting, however, care is generally limited to the cancer episode, not prediagnosis or posttreatment. Primary care of survivors commonly reverts back to a primary care physician who is not affiliated with the cancer care center. However, many cancer centers have begun to take a more proactive role in survivor care as its importance has gained recognition.

		Figure 2. Site of Cancer Care, Actual and Projected, 2006-2015

Site-of-care data from 2006 to 2010 sourced from the 2011 Drug Trend Report: The Express Scripts Research & New Solutions Lab. Projected site-of-care data from 2011 to 2015 generated by Inside Oncology, LLC.

		IDN indicates integrated delivery network.

		Source: Reprinted with permission from Inside Oncology. Academic Cancer Centers: Trends Impacting Key Account Management; 2012. http://www.insideonc.com. Accessed October 10, 2012.

Perhaps the truest form of integrated cancer care is the type delivered by the large full-service IDNs at the top of the NCQA rankings. These institutions offer care that extends beyond cancer diagnosis and treatment to targeted detection, prevention, and survivorship care.

 This version of integrated care is in accordance with the Commission on Cancer’s (COC) Cancer Program Standards 2012: Ensuring Patient-Centered Care, which mandates care throughout the cancer continuum, from prevention through end-of-life care or survivorship.

 Cancer centers may provide prevention and screening services, but often these services are offered at the community level and not targeted to specific patients. These stand-alone interventions, while beneficial, may not be as effective overall as those delivered as part of an organized program integrated into comprehensive long-term patient encounters.

In other models of integrated care delivery, community oncologists are banding together into statewide or regional conglomerates such as Regional Cancer Care Associates (RCCA) of New Jersey, formed in January 2012. According to RCCA president Andrew L. Pecora, MD, by the end of 2012, the group will provide care for about half of patients newly diagnosed with cancer in the state of New Jersey. Among the initiatives being implemented by the group are cost-conscious protocols, networkwide integration of electronic medical record (EMR) systems, real-time overall and progression-free survival tracking software, and survivorship care planning in collaboration with local primary care physicians. “If I was to do this as a single doctor in my individual practice, it might be interesting; if we are doing it in an entire state…we will move the needle,” said Pecora.

In another model aimed at community oncology, McKesson Specialty Health offers tools to support delivery of integrated cancer care by practices belonging to The US Oncology Network, which is one of the nation’s largest networks of community-based oncology physicians. “For more than 15 years our affiliated practices have been pulling together resources our patients need into a single building in the community setting,” said Matt Brow, vice president of public policy and reimbursement strategy for McKesson Specialty Health. Brow said it is important to distinguish this type of quality- and value-driven initiative by oncologists from the trend of hospital systems buying up everything in their vicinity. For radiation oncologist Gregory Patton, MD, practice president, Compass Oncology in Portland, Oregon, being part of The US Oncology Network has been beneficial in terms of the resources and skilled professionals it offers. “The strength of the network is that its leadership and initiatives evolve from the practices,” he commented.

J. Russell Hoverman, MD, PhD, medical director of managed care for The US Oncology Network, discussed the challenges of delivering truly integrated care in the community setting. “We have a lot of things in our network that would fit into IDN but they are not all in the same place,” said Hoverman. Moving forward toward integration that is more complete will require cooperation with groups outside of their network, platforms for communication, incentives, and perhaps, payment change. “We are continuously looking at models in which we could do all this; I think we all agree this is the direction we need to head.” He also discussed how he would like to form long-term relationships with payers, rather than 1- or 2-year relationships, so they can collaboratively learn from and build on existing pathways and integrated care processes.

Well-designed, integrated cancer care systems are positioned to provide the types of services increasingly being recognized as essential to good cancer care by performance monitoring groups like the COC.

 Proponents of healthcare systems that integrate care throughout a cancer patient’s life journey talk about the benefits of team care, quick response, accountability, research integration, and systematic implementation of medical evidence, as well as the facilitation of screening and early detection programs.

 Ultimately, the benefits of integration should improve survival outcomes for patients. Cancer care delivery organizations are beginning to look beyond surrogate quality indicators to primary health outcomes. Kaiser Permanente’s most recently reported 5-year cancer survival rates were higher than the national average—in some cases 10% higher&mdash;for nearly every disease state (see 

 “It is not just that we have great oncologists, but also because we do a lot of screening, prevention, and proactive patient support,” said Joanne Schottinger, MD, assistant medical director for Quality at Kaiser Permanente in Southern California. “Our patients are with us an average of 17 years; these people do well not only because they saw us as a cancer patient, but also because of the care they received outside of that phase. Everything else that needs to be done is being supported. It is an integrated network that leads to results like that.”

		Figure 3. Overall 5-Year Melanoma Survival Rates of Patients With Melanoma Within the Kaiser Permanente Southern California Health Plan Compared With US Average (2002-2008)

		Survival can be calculated by different methods for different purposes. The survival statistics presented here are based on relative survival, which measures the survival of cancer patients compared with the general population to estimate the effect of cancer. The overall 5-year relative survival for 2002-2008 from 18 SEER geographic areas was 91.2%. The 5-year relative survival by race and sex was 88.9% for white men, 93.4% for white women, 62.5% for black men, and 78.5% for black women (

http://seer.cancer.gov/statfacts/html/melan.html#survival

). KP indicates Kaiser Permeuante; SEER, Surveillance, Epidemiology and End Results.

		Source: Reprinted with permission from Kaiser Permanente. Letter from the CEO, George Halvorson. Celebrating cancer care successes at Kaiser Permanente. July 6, 2012.

With a heavy focus on early detection, Kaiser Permanente has set an organizational goal of having the lowest number of stage 3 and 4 cancers in the country. Its fully integrated EMR system was customized to fit its oncology needs and features tools that make every single patient visit, for any purpose, an opportunity to deliver clinical prevention services or to schedule a screening. Through its organized colon cancer screening program, which includes mailed fecal screening kits, the number of colon cancers detected at the treatable stages of 0 or 1 has improved to 41%, which is a 28% increase. Likewise, the number of late-stage colon cancers detected has decreased by 32% to just 13%. This work extends to other cancers as well (eg, breast and cervical), in which similar results have been garnered. According to Schottinger, they also attribute positive outcomes to robust prevention programs that focus on smoking cessation, alcohol use reduction, and overall wellness.

Through their EMR systems, IDNs share standardized point-of-care decision support, protocols, and patient information among all healthcare personnel within a network. “Being within an organized IDN offers opportunity for better care for patients and better communication through EMRs. These systems are organized so that providers can manage cases together,” said Guy. New health information technologies will allow organizations such as RCCA to share patient electronic health information across multiple disparate EMR platforms, avoiding the need for groups who have already made an investment in an EMR system to make changes.

EMRs have contributed greatly to standardization of cancer care across large provider networks through incorporation of continuously updated evidence-based treatment pathways. The US Oncology Network, a pioneer in this area, has published studies documenting maintained outcomes with improved practice standardization and reduced costs through the use of cost-conscious pathways that are disseminated network-wide via their proprietary electronic health record system.

IDNs that use EMRs in conjunction with a team-based approach have also been able to enhance quality assurance and reduce chemotherapy-related error rates. Oncology pharmacists at Kaiser Permanente who monitor and manage patient safety have prevented 99.7% of patients with poor renal function from getting worse and 95.9% of patients on chemotherapy from developing anemia.

Furthermore, EMRs have advanced the power of clinical research programs within the IDNs. Hornbrook explained that the benefits have been tremendous in terms of increases in the availability, accessibility, and amount of data, as well as reduced workload (eg, chart abstractions). “We can do translational research out of (our EMRs),” said Schottinger. “That is really an exciting part for us…we get to look at how real people are responding to these regimens in the real world and build in the support that they need.” IDNs are capable of rapidly disseminating and deploying not only their own research-based safety responses, but also any externally issued medication or device safety alerts.

Nonetheless, not all efforts at integrated health delivery are going to be effective. As discussed in a recent report by the US Government Accountability Office, the delivery of high-quality care must be the mission at the outset.

 At this point, clear documentation associating cost and quality outcomes with IDN-provided care is not available.

 The variations in the extent of clinical and financial integration of existing IDNs make evaluation, comparison, and metaanalyses difficult. “The field is still in its infancy in terms of measuring what integrated care is, what it should be, and what expectations should be,” said Hoverman.

Growing evidence suggests that consolidation of healthcare providers and hospitals in a market opens the door for the resulting health system to charge payers more for their services and reduces market pressure to provide patients with value-based, high-quality care.

“When cancer doctors are employed by hospitals, costs go up in spades,” said Brow. He based this statement on reports prepared by healthcare consulting firms Avalere Health and Milliman that analyze site-of-service—related costs of cancer care.

 “The bigger a health system gets, the more leverage it has against the payer, the more indispensable it is to the payer,” said Brow.

Hospital systems argue that the higher reimbursement rates they receive for delivering chemotherapy are offset by other services they provide that are not available at private oncology practices, and by the fact that they are required to care for larger numbers of uninsured and underinsured patients. On the other hand, said Guy, the current fee-for-service model also incentivizes community oncologists to use the most expensive drugs to maximize reimbursement.

A 2010 report by AcademyHealth cited some of the potential clinical benefits and elimination of duplicate services that can result from integrating services for patients within a single organization.

 Nonetheless, some motivations for integration may be geared toward increasing volume and revenue, not cost containment or quality improvement.

 Evidence suggests that consolidation motivated by reasons other than efficiency will not garner efficiency.

			United States Government Accountability Office. Health care delivery: features of integrated systems support patient care strategies and access to care, but systems face challenges. GAO- 11-49. 

. Published 2010. Accessed October 10, 2012.

			Bach P. How many doctors does it take to treat a patient? 

			Kelley R. Where can $700 billion in waste be cut annually from the US healthcare system? 

			Enthoven AC. Integrated delivery systems: the cure for fragmentation. 

			National Commission for Quality Assurance. NCQA’s health insurance plan rankings 2012- 2013: private plan details. 

http://www.ncqa.org/Portals/0/Report%20Cards/Rankings/ hpr2012privatedet.pdf

. Published September 20, 2012. Accessed October 10, 2012.

			Health Insurance. Consumer Reports. November 2012:40-49.

			Hewitt ME, Simone JV; National Cancer Policy Board (US). Ensuring Quality Cancer Care. Washington, DC: National Academies Press; 1999. 

http://search.ebscohost.com/login. aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=14721

			Commission on Cancer. Cancer program standards 2012: ensuring patient-centered care v1.0. 

http://www.facs.org/cancer/coc/standards.html.

 Published 2012. Accessed October 10, 2012.

			Clauser SB, Wagner EH, Aiello Bowles EJ, Tuzzio L, Greene SM. Improving modern cancer care through information technology. 

			Bickell NA, LePar F, Wang JJ, Leventhal H. Lost opportunities: physicians’ reasons and disparities in breast cancer treatment. 

			Kolodziej M, Hoverman JR, Garey JS, et al. Benchmarks for value in cancer care: an analysis of a large commercial population. 

			Inside Oncology. Academic cancer centers:trends impacting key account management; 2012. 

			Association of Community Cancer Centers. Cancer care trends in community cancer centers: a survey of ACCC membership 2012. Published 2012.

			Hewitt ME, Greenfield S, Stovall E; National Cancer Policy Board (US). Committee on Cancer Survivorship: Improving Care and Quality of Life. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2006.

			National Commission for Quality Assurance. The state of health care quality 2011. 

http://www.ncqa.org/Portals/0/Publications/Resource%20Library/SOHC/SOHC%202011-v2- web_2.22.12.pdf.

 Published 2011. Accessed October 10, 2012.

			Levin TR, Jamieson L, Burley DA, Reyes J, Oehrli M, Caldwell C. Organized colorectal cancer screening in integrated health care systems. 

			Dalton WS, Sullivan DM, Yeatman TJ, Fenstermacher DA. The 2010 Health Care Reform Act: a potential opportunity to advance cancer research by taking cancer personally. 

			National Cancer Institute. Surveillance Epidemiology and End Results. 

			Neubauer MA, Hoverman JR, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of non-smallcell lung cancer in the community setting. 

			Hoverman JR, Cartwright TH, Patt DA, et al. Pathways, outcomes, and costs in colon cancer: retrospective evaluations in two distinct databases. 

			AcademyHealth. Research insights: integration, concentration, and competition in the provider marketplace. 

http://www.academyhealth.org/files/publications/AH_R_Integration%20 FINAL2.pdf.

 Published 2010. Accessed October 10, 2012.

			Alexander A, Garloch K, Neff J. Prices soar as hospitals dominate cancer market. Charlotte Observer, September 24, 2012. 

http://www.charlotteobserver.com/hospitals

			Jameson M. As hospitals take over doctors’ practices, fees rise. Orlando Sentinel, September 15, 2012. 

http://articles.orlandosentinel.com/2012-09-15/health/os-hospitals-buyphysicians-20120915_1_hospital-executives-hospitalemployeephysician-practices

			Avalere Health. Total cost of cancer care by site of service: physician office vs outpatient hospital. Avalere Health; 2012. 

http://www.avalerehealth.n/news/2012-04-03_COA/Cost_of_Care.pdf

. Published 2012. Accessed October 10, 2012.

			Finch K, Pyenson B. Milliman client report: site of service cost differences for Medicare patientsreceiving chemotherapy. 

http://www.communityoncology.org/UserFiles/pdfs/ millimansite-of-service-cost-differences-medicare-report.pdf

. Published 2011. Accessed October 10, 2012.

Articles

Is Our Healthcare System Ready to Integrate Cancer Care?

Beyond providing prognostic information, molecular biomarkers can help optimize therapy decisions. Predictive biomarkers are beginning to help physicians assign value to associated therapies in terms of likelihood of benefit and benefit-to-risk profiles for individual patients. A predictive factor is a baseline patient or tumor characteristic that identifies a specific qualitative outcome (eg, response or survival) driven by a treatment.

Healthcare providers and payers hope to be able to use predictive biomarkers to rationally apportion therapy. “We want to enrich the treated population with those who are likely to benefit from therapy,” explained Mark Green, MD, chief medical officer, Xcenda, who led the roundtable discussion 

Prognostic vs Predictive Biomarkers and the Role of Companion Diagnostic Testing in Payer Decision Making

 during the 2012 Academy of Managed Care Pharmacy Annual Meeting. “Individuals likely to benefit should be willing to accept the risks of receiving that therapy— namely, costs for that particular treatment, loss of opportunity to try something else at that point in time, and treatment-related toxicities,” said Green.

On the other hand, he said, “Individuals whose tumors fail to express a biomarker directly predictive of a reasonable likelihood of response to a certain therapy would be much better served by exploring other therapies and not exposing themselves to an extremely low likelihood of benefit with no reduction in risk.” The loss of opportunity for trying an alternative therapy that might offer a better chance for response is a significant risk to this group.

When a biomarker test is capable of predicting response to a particular therapy, payers should have the opportunity to incorporate that test into their drug benefit management strategy. It is Green’s opinion that by encouraging and covering testing, payers can facilitate rational treatment and coverage decisions. He is expecting that electronic medical records will help bolster awareness, buy-in, and integration of biomarker testing.

According to Green, the field is still finding its way in actualizing the use of biomarkers, not only for therapy selection but for coverage decision making. “It is a new world for providers, payers, patients, and the entire consortium of healthcare stakeholders, but we have to make rational use of them,” he commented.

Applying biomarkers in this way, he cautions, will require discipline and biomarker assays of excellent quality that are associated with high reproducibility, specificity, sensitivity, and accuracy. It will also require stakeholders to agree upon test criteria, thresholds, and decisions related to companion diagnostics. Once that happens, according to Green, plans and providers should be in a position to address the optimum strategy for care. “It is evidence-based, it is science-driven, it is an opportunity cost for optimized patient care and it is a responsible behavior. That is what we are striving for and that is where we need to be going,” he remarked.

		Table. Locally Advanced or Metastatic ALK-Positive NSCLC Efficacy Results

		CR indicates complete response; NSCLC, non—small cell lung cancer; PR, partial response.

 Investigated in 2 multicenter, single-arm studies (studies A and B).

: Xalkori [package insert]. New York, NY: Pfizer Labs; 2011. 

An exciting development in the field of predictive diagnostics is the FDA approval of crizotinib (Xalkori), along with a companion diagnostic test, for patients with ALK-positive locally advanced or metastatic non—small cell lung carcinoma (NSCLC). Although crizotinib costs more than $9000 per month, the response rates in patients with ALK-positive tumors are dramatic. The majority of eligible patients responded to therapy (

), demonstrating the robust enrichment in likelihood of response achievable with predictive biomarkers.

Giving these targeted agents a try in everyone is not an advantageous approach for a number of reasons. These drugs are extremely expensive and there is the issue previously raised about giving someone a therapy from which they are not likely to benefit while exposing them to all the associated costs. The overall rate of response to EGFR inhibitors among patients with advanced NSCLC positive for an EGFR mutation is around 70%, while in patients without an EGFR mutation, it is essentially zero. Use of the EGFR inhibitor gefitinib as initial therapy for patients with EGFR mutation—negative tumors suggests targeted therapy can actually worsen progression-free survival (

). In addition, some trials show that if you do not test and instead simply randomly assign patients to either erlotinib or chemotherapy as first-line therapy, overall survival may be significantly worse in those individuals who are assigned to receive targeted therapy rather than chemotherapy as first-line management. Green elaborated, “So you have to have the test results if you want to use this targeted therapy in the first-line setting and if the patient carries a mutation and you use gefitinib or erlotinib first-line, the likelihood of response is extremely high.”

	Figure. Kaplan-Meier Curves for Primary End Point of Progression-Free Survival in Patients Receiving Either Carboplatin-Paclitaxel or Gefitinib

Green reiterated the goal of predictive therapy as, “You want to be able to dichotomize a population into those who have a high likelihood of benefit and those who do not.” The key, he says, is to avoid missing that person who has a chance to receive a therapy that may provide a 70% to 80% chance of response and has been shown to remain active at 12 months or longer. “We are looking to be able to rationalize, not in the sense of justify, but in the sense of being able to think clearly of how to assign therapeutic recommendations.”

CI indicates confidence interval; EGFR, epidermal growth factor receptor.

A, Overall population of patients; B, patients who were positive for the EGFR mutation; C, patients who were negative for the EGFR mutation; and D, patients with unknown EGFR mutation status.

Analyses were performed on an intention-to-treat population.

: Reprinted with permission from Mok TS, Wu Y-L, Thongprasert S, et al. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. 

 The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.

Predictive biomarkers are beginning to help physicians assign value to associated therapies in terms of likelihood of benefit and benefit-to-risk profiles for individual patients.

Rationalizing Treatment and Coverage Decisions With Predictive Biomarkers

		Figure 1. Cancer Is Payers’ Number 1 Management Priority

To what degree is each of the following categories an overarching management priority?

Managed Care Benefit Design Index, Fall 2011

 (a survey of payers, N = 101), cancer topped the list of payers’ management priorities for the first time.

: Reprinted with permission from The Zitter Group. 

, cancer was the top-ranked management priority among payers (

). Mark Zitter, CEO, The Zitter Group, explained the reason for their concern: “Typically it is often cost-related and challenge-of-management-related, so this is clearly an issue for payers.”

	To keep abreast of practice and management trends in oncology, The Zitter Group issues the 

, the results of a semiannual survey of 100 payers, 100 oncologists, and 100 oncology practice managers.

Oncology Pathway Development and Implications for Managed Care

 at the 2012 Academy of Managed Care Pharmacy Annual Meeting, Zitter presented 2011 MCOI data and reviewed the rationale underlying clinical pathway use, current utilization trends, perspectives on pathway use, and implications for managed care pharmacy.

	Survey respondents estimated that 16% to 23% excess cost can be eliminated from cancer treatment without adversely affecting quality of care or health outcomes. The cause of excess spending most commonly cited by payers and oncologists was excessive end-of-life treatment (35% payers, 30% oncologists). Other contributors to wasteful spending include inappropriate drug use and diagnostic testing, suboptimal distribution of prescription drugs, and utilization management requirements.

	Payers are employing a number of traditional benefit management approaches to control spending. Prior authorization is by far the most commonly employed strategy. In cancer care, payers use prior authorization as a way to ensure appropriate utilization. Ultimately, payers and doctors agree that it is the doctors who drive treatment decisions. Hence, it seems logical that doctors should drive cost reduction. That, explained Zitter, is where clinical pathways come into play.

	Doctors don’t like the typical payer responses to increased oncology costs: reimbursement reductions, prior authorizations, and specialty pharmacy or other site-of-care mandates. Pathways offer a more palatable alternative toward reducing practice variation, improving outcomes, and reducing cost.

	A pathway represents an evidence-based approach to care that focuses on a specific disease or patient group with a relatively predictable course. For each disease or patient group, the pathway specifies which interventions to perform and in which sequence to use them. Pathway generation and maintenance requires a process for evaluating therapies and clinical approaches.

	Forty percent of the payers surveyed already had pathways in place and the majority of those who did not indicated that they were likely to implement clinical treatment pathways in the near future (within 18 months of survey). Breast, lung, and colorectal cancers were the tumor types most commonly covered by clinical pathways (

). Payers and oncologists were optimistic that cancer care guidelines will improve the quality of cancer care and reduce cancer costs.

		Figure 2. Payers Have Adopted Pathways for the Most Common Cancer Types

Does your organization currently apply clinical treatment pathways to manage cancer therapies?

		Among the 40% of payers who have adopted clinical oncology pathways, breast, lung, and colorectal cancer were the most commonly covered tumor types.

	Pathways are typically developed by individual provider groups or national organizations (eg, National Comprehensive Cancer Network, American Society of Clinical Oncology), not by health plans. Nearly 80% of payers agreed that they would rather enforce externally produced cancer care guidelines than create and enforce internally created pathways. Indeed, nearly 70% of those who had already adopted clinical pathways indicated that a third party pathway organization was responsible for pathway management. Although managed care is not typically involved in pathway development, pharmacists can play a significant role in informing the development process by providing data, vetting the pathways, and assisting with pathway enforcement.

	Several reasons were cited among those who had chosen not to adopt clinical pathways. The most common were that their organizations had not reached consensus on which pathways to develop and that the management techniques in place were considered effective. Interestingly, these were also the top two reasons cited by oncologists who were not planning to adopt clinical pathways in the next 2 years. Adoption of clinical pathways does not necessarily mean that traditional management approaches need to be abandoned. About half of the payers integrated treatment algorithms into their existing prior authorization process.

	Ultimately, for clinical pathways to be effective, the oncologists have to be using them. With that in mind, health plans are devising a number of ways to incentivize pathway use. According to payers surveyed, higher drug reimbursements and reduced administrative requirements (eg, prior authorization) are the most frequently applied incentives for physicians who adhere to pathways. Less commonly used incentives are expedited utilization reviews and reimbursement processing, in-network requirements, and preferred provider status within network. According to the MCOI, getting doctors on pathway may not be too difficult. The oncologist respondents found pathways influential and were in favor of their use. Of 60 oncologists surveyed, just less than half said they plan on adopting pathways within the next 2 years.

Stakeholders weigh in on evidence-based pathway approach designed to decrease practice variation, improve outcomes, and reduce cost.

Kim Farina, PhD

Articles

Is Our Healthcare System Ready to Integrate Cancer Care?

Rationalizing Treatment and Coverage Decisions With Predictive Biomarkers

How Payers and Oncologists Really Feel About Clinical Pathways

Kim Farina, PhD

Articles

Is Our Healthcare System Ready to Integrate Cancer Care?

Rationalizing Treatment and Coverage Decisions With Predictive Biomarkers

How Payers and Oncologists Really Feel About Clinical Pathways

Is Our Healthcare System Ready to Integrate Cancer Care?