For patients receiving chemotherapy, drugs represent the largest cost. Clinical chemotherapy Pathways have become a critical strategy to identify unnecessary drug costs and to implement mechanisms to deliver lower cost alternatives without sacrificing outcomes or quality of care. This paper describes the steps of development of a functioning pathways program beginning in an environment of full-risk capitation, including drugs. The next steps involved quantitating the potential impact of such a program and then collaborating with a payer to test the concept. When these studies showed promise, the practices adopting pathways used them as a backbone for drug management in the Oncology Care Model. These experiences very likely represent steps in a continuum towards placing more of the drug delivery costs at risk. The potential for again considering capitated payments is discussed.
References
[1]
Blum, J.L., Jones, S., Fay, J.W., et al. (1997) Guidelines for Systemic Therapy of Early Stage Breast Cancer. Breast Cancer Research and Treatment, 43, 259-278.
https://doi.org/10.1023/A:1005705300012
[2]
James, B.C. and Eddy, D.M. (1994) CPI and Practice Guidelines. In: Horn, S.D. and Hopkins, D.S., Eds., Clinical Practice Improvement: A New Technology for Developing Cost-Effective Quality Health Care, Faulkner & Gray, Washington DC, Chapter 9.
[3]
Hoverman, J.R. and Robertson, S.M. (2004) Lung Cancer: A Cost and Outcome Study Based on Physician Practice Patterns. Disease Management 7, 112-123.
[4]
Hoverman, J. (2011) Hard Times for Oncologists? Journal of Oncology Practice, 7, 82s-84s. https://doi.org/10.1200/JOP.2011.000416
[5]
Brow, M.E., Okon, T.A., George, E.T., et al. (2012) Thoughts and Recommendations on Cancer Care Site of Service. Community Oncology, 9, 382-388.
https://doi.org/10.1016/j.cmonc.2012.11.004
[6]
Community Oncology Alliance. The Changing Landscape of Oncology Care.
https://communityoncology.org/2020-community-oncology-alliance-practice-impact-report/
[7]
Neubauer, M., Hoverman, J., Kolodziej, M., et al. (2010) Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non-Small-Cell Lung Cancer in the Community Setting. Journal of Oncology Practice, 6, 12-18.
https://doi.org/10.1200/JOP.091058
[8]
Hoverman, R., Cartwright, T., Patt, D., et al. (2011) Pathways, Outcomes, and Costs in Colon Cancer: Retrospective Evaluations in Two Distinct Databases. Journal of Oncology Practice, 7, 525-595.
[9]
Kolodziej, M., Hoverman, J., Garey, J., et al. (2011) Benchmarks for Value in Cancer Care: An Analysis of a Large Commercial Population. Journal of Oncology Practice, 7, 301-306. https://doi.org/10.1200/JOP.2011.000394
[10]
Hogan, C., Lunney, J., Gabel, J. and Lynn, J. (2001) Medicare Beneficiaries’ Costs of Care in the Last Year of Life. Health Affairs, 20, 188-195.
[11]
Emanuel, E., Ash, A., Yu, W., et al. (2002) Managed Care, Hospice Use, Site of Death, and Medical Expenditures in the Last Year of Life. Archives of Internal Medicine, 162, 1722-1728. https://doi.org/10.1001/archinte.162.15.1722
[12]
Wright, A., Zhang, B., Ray, A., et al. (2008) Associations between End-of-Life Discussions, Patient Mental Health, Medical Care near Death, and Caregiver Bereavement Adjustment. JAMA, 300, 1665-1673. https://doi.org/10.1001/jama.300.14.1665
[13]
Lundquist, G., Rasmussen, B. and Axelsson, B. (2011) Information of Imminent Death or Not: Does It Make a Difference? Journal of Clinical Oncology, 29, 3927-3931.
[14]
Detering, K., Hancock, A., Reade, M. and Silvester, W. (2010) The Impact of Advance Cancer Planning on End of Life Care in Elderly Patients: Randomized Controlled Trial. BMJ, 340, c1345.
[15]
Temel, J., Greer, J., Muzikansky, A., et al. (2010) Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. The New England Journal of Medicine, 363, 733-742. https://doi.org/10.1056/NEJMoa1000678
[16]
Smith, T., Temin, S., Alesi, E., et al. (2011) American Society of Clinical Provisional Clinical Opinion: The Integration of Palliative Care into Standard Oncology Care. Journal of Clinical Oncology, 38, 5161.
[17]
Hoverman, J.R., Klein, I., Harrison, D.W., et al. (2014) Opening the Black Box: The Impact of an Oncology Management Program Consisting of Level 1 Pathways and an Outbound Nurse Call System. Journal of Clinical Oncology, 10, 63-67.
https://doi.org/10.1200/JOP.2013.001210
[18]
Hoverman, J.R., Neubauer, M.A., Jameson, M., et al. (2018) Three-Year Results of a Medicare Advantage Cancer Management Program. Journal of Oncology Practice, 14, e229-e237.
[19]
Winn, R.J. and McClure, J. (2003) The NCCN Practice Guidelines in Oncology: A Primer for Users. Journal of the National Comprehensive Cancer Network, 1, 6-13.
https://doi.org/10.6004/jnccn.2003.0003
[20]
Waters, T.M., Kaplan, C.M., Graetz, et al. (2019) Patient-Centered Medical Homes n Community Oncology Practices: Changes in Spending and Care Quality Associate with the COME HOME. Journal of Oncology Practice, 15, e56-e64.
https://doi.org/10.1200/JOP.18.00479
[21]
Newcomer, L.N. (2012) Changing Physician Incentives for Cancer Care to Reward Better Patient Outcomes Instead of Use of More Costly Drugs. Health Affairs (Millwood), 31, 780-785. https://doi.org/10.1377/hlthaff.2012.0002
[22]
Ellis, P.G., O’Neil, Earle, M.F., et al. (2017) Clinical Pathways: Management of Quality and Cost in the Metastatic Colorectal Cancer Setting. Journal of Oncology Practice, 13, e346-e352. https://doi.org/10.1200/JOP.2016.019232
[23]
Hertler, A., Chau, S., Khetarpal, R., et al. (2020) Utilization of Clinical Pathways Can Reduce Drug Spend within the Oncology Care Model. JCO Oncology Practice, 16, e456-e463.
[24]
Wilfong, L., Ginsburg, A., Hoverman, J.R., et al. (2020) Treatment Pathways for First-Line Metastatic Non-Small Cell Lung Cancer: Cost and Survival. Journal of Clinical Pathways, 6, 52-57.
[25]
Dorn, S. (2020) The COVID-19 Pandemic and Resulting Economic Crash Have Caused the Greatest Health Insurance Losses in American History.
https://familiesusa.org/resources/the-covid-19-pandemic-and-resulting-economic-crash-have-caused-the-greatest-health-insurance-losses-in-american-history/
[26]
Dreyer, T., Wilfong, L.S., Patel, K., et al. (2021) Oncology Care Model: A Herculean Effort with Fixable Fatal Flaws. JCO Oncology Practice, 16, e1433-e1440.
[27]
Carlson, R.W., Scavone, J.L., Koh, W., et al. (2016) NCCN Framework for Resource Stratification: A Framework for Providing and Improving Global Quality Oncology Care. Journal of the National Comprehensive Cancer Network, 14, 961-969.
https://doi.org/10.6004/jnccn.2016.0103
