State Oncology Groups Advance Clinical Pathways

PathwaysIndiana Oncology Society's recent decision to endorse the pathways services of P4 Healthcare marks the third regional oncology organization to take a position on cancer care pathways. “Increasingly, insurers are mandating that health care providers follow certain quality measures, or pathways, that define what constitutes appropriate services for the majority of our patients,” Naveed Chowhan, MD, President of the Indiana society, said in a news release announcing the decision. “IOS is approaching this preemptively to ensure that cancer care providers not only assist in the development of the pathways to be used in Indiana, but are comfortable with them as well.” The Indiana group follows the lead of Oncology Physician Resource (OPR), a physician-owned group purchasing organization in Michigan. OPR worked with the state's biggest insurer to develop a voluntary pathways program that went into effect in January 2010. Meanwhile, in mid-2010, the Association of Northern California Oncologists (ANCO) board of directors endorsed the concept of cancer care pathways and identified Innovent Oncology and Via Oncology as “preferred vendors.” Innovent Oncology, an affiliate of US Oncology; P4 Healthcare; and Via Oncology, an affiliate of UPMC oncology departments, are the first three promoters of cancer care pathways. (For a description of the three, see the 10/25/10 issue of OT:http://bit.ly/9bNtNa.) What's Happening in Indiana In the P4 pathways model, physicians in a geographic area work together to identify the pathway that should be for a given tumor type. While they all review the same evidence, physicians in one part of the country may prefer one or more protocols while those in another area choose a different set of treatment options. A physician's compliance with pathways is determined by insurance claims. The Indiana society recommended that the state's oncology practices work with P4 to collect statewide data and help develop the clinical pathways that will be used on a voluntary basis throughout Indiana. Dr. Chowhan, Medical Director of the Floyd Memorial Cancer Center of Indiana, declined to be interviewed for this article. In endorsing P4, the society said that oncology practices that participate in the pathways program may receive financial incentives from insurers and the opportunity to benchmark their own treatment and quality against others. To encourage the use of cancer care pathways, the state society is encouraging Anthem, the state's primary insurer, to contract with P4 to conduct a cancer pathways pilot project. ANCO's Approach In Northern California, the ANCO board of directors took a different tact. Rather than endorsing one or more pathways vendors, it endorsed the “front-end compliance model” used by Via and Innovent. Unlike P4, those two companies have oncologist-led committees at the corporate level that determine pathways, and decision-support systems prompt oncologists to comply with the pathway or identify a reason for not doing so. Thus, compliance is determined at the beginning of treatment rather by reviewing insurance claims. “We have not endorsed Innovent or Via,” said Jose Gonzalez, ANCO's Executive Director. “We have partnered with them in trying to disseminate information about this type of program, and we have vetted them and told our members, ‘These are two good ones to look into.’” Despite ANCO's leadership on the pathways issue, most of its members are staying on the sidelines, he said. While a few large practices are exploring their pathways options, the small practices that provide most of the cancer care in northern California are not. “To be honest, I can't really say I'm surprised by the lack of enthusiasm in embracing this particular change in the oncology marketplace,” he said. “I can say that I'm personally disappointed.” Gonzalez attributes the lack of interest, in part, to concern that adopting cancer care pathways may reduce a practice's revenues because pathways are chosen based on a treatment's efficacy, side effects, and cost. Small practices, in particular, fear that they will be unable to negotiate insurance contracts that reward them for delivering standardized best practice care. He said that while he understands that concern, he wants ANCO members to be proactive in moving to “value-based” payment systems that reward physicians for the quality and efficiency of the care they deliver, rather than the cost and volume of therapeutic agents they prescribe.Association of Northern California Oncologists Executive Director JOSE GONZALEZ: “We have not endorsed Innovent or Via. We have partnered with them in trying to disseminate information about this type of program, and we have vetted them and told our members that they are two good ones to look into.”“Fee-for-service is an endangered species and will be going away,” he says. “Those that learn about [value-based payment] and take whatever steps are available to them to structure programs that are mutually beneficial to the contracting entities will survive and prosper, and those that don't will suffer the consequences.” Michigan Experience In Michigan, cancer care pathways have been embraced to a much greater degree than its original advocates would have predicted. The Michigan Oncology Clinical Pathways program launched in January 2010, and 80% of community oncology practices—along with the Barbara Ann Karmanos Cancer Center and the Josephine Ford Cancer Center at the Henry Ford Health System—have been participating from the outset. “We are pretty proud that, as far as we know, this is the only provider-driven quality initiative in the country,” said OPR Vice President Kurt H. Neumann, MD. (OPR was created by the Michigan Society of Hematology and Oncology; the two organizations are separate, but they work closely together.) Blue Cross Blue Shield of Michigan, the dominant insurer in the state, initiated a discussion between OPR and P4 Healthcare in 2009. OPR, which is comprised of nearly 60 oncology practices in Michigan and nearby states, designed the program and chose P4 to be the technology subcontractor. OPR chose 13 oncologists from community and academic practices around the state to serve on the pathways steering committee. The steering committee reviewed evidence-based guidelines and determined the pathways for lung, colon, and breast tumors. Under the contract between OPR and the insurer, each physician participating in the pathways program received a $5,000 upfront participation reward. The program is available to all oncologists in the state, regardless of whether they are OPR members. Drug reimbursement rates were changed to eliminate any financial incentive for prescribing expensive brand-name drugs instead of generic drugs. Additionally, the parties agreed that any savings on drug expenses would be shared between the physicians and Blue Cross, although the process for calculating savings was not defined. Results to Date About 190 physicians in some 50 practices participated in the first year, Dr. Neumann said, and all continued in 2011. All participating physicians met the threshold for compliance, meaning that they adhered to the pathways for 70% of their lung, breast, and colon cancer patients and complied with supportive care protocols for 80% of their patients. Although OPR, Blue Cross, and P4 agree that the pathways program reduced cancer drug spending, the exact amount of savings — and, in fact, the best way to measure savings—has not yet been determined. “We are working hard at that and are comfortable with the positions that each are taking, but we just haven't been able to come to a number that we all agree on,” Dr. Neumann said.KURT NEUMANN, MD, Vice President of Oncology Physician Resource, created by the Michigan Society of Hematology and Oncology: “We are pretty proud that, as far as we know, this is the only provider-driven quality initiative in the country.”In light of that, Blue Cross this year is increasing its payment for evaluation-and management codes by 10 percent for the oncologists participating in the program, rather than giving a “shared savings” payout. When the drug savings for the 2010 pathways program is calculated, a lump sum will be paid to all participants. The pathways program was expanded in 2011 to include clinical pathways for prostate, ovarian, and three other cancers. What Does Compliance Mean? The high rate of participation — and the high rate of compliance among participating oncologists — in Michigan reflects the fac t that the Michigan program allows a wide range of treatment options to be considered “on pathway.” While having a single pathway would decrease treatment variability and likely reduce the costs of care, that approach would have rebuffed by many physicians, Dr. Neumann said. “To jump in on Day 1 and tell [oncologists] that there was a single preferred option, and that if they didn't use that, they would have to explain why, we never would have been able to get the participation that we were looking for,” he said. The data collected during the first year of the pathways program identifies for the first time how oncologists are actually treating patients with lung, colon, and breast cancers. In each cancer type, Dr. Neumann said, most oncologists are choosing one of five or six options. “One of our goals for Year 3 will be to narrow down the pathways, fully realizing that that will…decrease the variability but probably not limit the physicians significantly,” he said. ‘Michigan Model’ May Be Catching on in Other States The “Michigan Model” for promoting the use of cancer care pathways may be catching on in other states. ION Solutions, a unit of AmerisourceBergen Corp., is currently helping to negotiate contracts between insurers and oncology groups across the country, said Kurt Neumann, MD, Medical Director for Quality Initiatives for ION Solutions. The contracts are designed to improve the quality of cancer care through the use of clinical pathways. “The model to promote true collaboration between the payers and the providers is the Michigan model. We at ION Solutions can provide infrastructure and consultation to help physicians create these programs,” he said. Dr. Neumann also serves as Vice President of Business Development for Oncology Physician Resource, the group purchasing organization that contracted with Blue Cross Blue Shield of Michigan for the pathways program in that state. ION Solutions is a sister company to another AmerisourceBergen subsidiary, Oncology Supply, which is one of the largest distributors of oncology products to private practice oncologists in the country.

Topic: Economic and Financial Impacts of Cancer
Subfield: Economics and Econometrics
Field: Economics, Econometrics and Finance
Domain: Social Sciences