In the Next Generation of Value-Based Contracting, Clinical Pathways Can Increase Accountability

This article was written in response to the Viewpoint: "Post-Election Pathways Will Focus on Patients’ Definition of Value"

 

The shift from fee-for-service to value-based payment systems is likely to continue, and clinical pathways afford the opportunity to incorporate detailed cost information and embed quality endpoints into the clinician-patient interface to support value-based care decisions. Provider-driven clinical pathways that focus on medical evidence and define the critical elements necessary to support patient choice and medical decisions provide an opportunity to instill greater accountability into the health care system.

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As described by Guerin and Stefanacci,1 changes in health care coverage with a Republican-led federal government are likely to result in greater patient engagement in health care decision-making. Indications are that the Patient Protection and Accountable Care Act of 20102 will be repealed and replaced with consumer-directed health care plans that increase patient choice through multiple mechanisms, including the expansion of health savings accounts tied to high-deductible health care plans, which allow the use of pre-tax dollars for day-to-day health care expenditures. These plans are intended to empower and educate the consumer regarding health care costs, with a goal of driving competition to decrease expenditures and improve quality. We agree that the development of patient-friendly clinical pathways that articulate treatment value propositions, in terms of treatment-related costs as well as outcomes of clinical significance, will provide greater transparency related to treatment options. 

Clinical pathways provide a high-level roadmap that defines major clinical milestones and makes specific recommendations for individual therapeutic interventions. Ideally, cancer clinical pathways also define the interdisciplinary interactions that support the complex and multimodality nature of cancer treatment. From a consumer standpoint, clinical pathways provide the opportunity to document the best-in-class care for patients. Patient-focused pathways not only allow patients to understand their treatment options, and the associated out-of-pocket costs, but also can identify the impact of care choices on quality of life and incorporate information regarding realistic outcomes. These components need to be viewed together. True transparency will require providing clearer information for patients and families related to value, cost, and quality, as well as addressing the added complexity of personalized medicine options.

Well-documented treatment choices cannot be viewed in a vacuum, however. A key component of patient-centricity is related to the model of care in which the providers work. Merely understanding therapeutic choices, but not understanding the ability of the individual health care provider or the associated health care organization to deliver complex care in an interdisciplinary approach, will not provide adequate information for the consumer nor improve the quality of health care decisions. High degrees of collaboration and collegial decision-making are fundamental; however, this has not been a model of care widely employed in this country outside of free-standing cancer hospitals or academic centers well-engrained in this health care delivery model. Thus, patients cannot be encouraged to view clinical pathways as a recipe for care that is readily duplicated from site to site. 

The benefits of improved patient engagement and stream-lined provider interactions will be a major step forward in the quest to create a patient-centered health care system that supports patients in managing and organizing their own health care. However, the opportunity to instill greater accountability into the health care system by utilizing provider-driven clinical pathways that focus on medical evidence and define the critical elements necessary to support patient choice and medical decisions will likely have a more profound impact on the development of an efficient and effective health care delivery system. Several studies have demonstrated that the use of cancer clinical pathways can decrease overall costs of care while preserving quality.3-6 While many available cancer pathways emphasize cost of care and primarily target cancer drug choices, the American Society of Clinical Oncology recently developed a policy statement emphasizing that oncology pathways “should support the development of comprehensive cancer care plans by addressing the full spectrum of cancer care that will maximize opportunities for value-based medical outcomes.”7 

Although cancer drugs are an important driver of cancer-related health care expenditures, a recent review of total annual costs of care for actively treated cancer patients from both commercial payer and Medicare data sources demonstrated that antineoplastic agents made up approximately 15–20% of the total costs of cancer care during the period of time from 2004 to 2014.8 Indeed, with the rapid explosion of new, effective, and costly biologic agents, the impact of drug costs as a proportion of cancer care-related expenditures is expected to rise, and it is appropriate to focus on this aspect of care. However, a large component of cancer-related costs is not associated with drug therapy. Clinical pathways that address the continuum of cancer care provide a greater opportunity to improve overall cost-effectiveness, avoid redundancies and inappropriate care, and improve quality. Pathways that provide information related to specific prognostic indicators, medical conditions, and other patient or disease-specific factors in order to stratify and personalize therapeutic choices; that emphasize medical, surgical, and radiation oncology options; that recommend diagnostic imaging strategies; that define the appropriate role of molecular diagnostics; and that incorporate opportunities for improved supportive and palliative care interventions are more likely to support cost-effective clinical decision-making and decrease the overall costs of cancer care.

The shift from fee-for-service to value-based payment systems is likely to continue, and clinical pathways afford the opportunity to incorporate detailed cost information and embed quality endpoints into the clinician-patient interface to support value-based care decisions. As a further step along the evolution to the vision of patient-centric decision-making, our center continues to work with payers to pilot and test new value-based reimbursement models that support high quality and cost effective care. We rely on clinical pathways to increase accountability by prospectively defining expected clinical care patterns and associated costs, measuring performance, and providing feedback to contribute to improved operational effectiveness. These pilots are critical to  defining factors that influence cost and designing the best programs for patients. We will continue to collaborate with all stakeholders—patients, providers, and payers—to clearly identify needs and develop the most relevant and useful information to understand patient out-of-pocket costs and quality of life requirements. Empowering patients with knowledge regarding treatment strategies and expected outcomes while actively engaging all cancer-related providers in cost effective decision-making will yield true accountability and improvements in health care delivery for the future. 

References

1.    111th Congress. The Patient Protection and Affordable Care Act. H.R. 3590. March 23, 2010.

2.    Guerin S, Stefanacci RG. Post-election pathways will focus on patients’ definition of value. Journal of Clinical Pathways. 2016;3(1):37-39. 

3.    Gordon SA, Reiter ER. Effectiveness of critical care pathways for head and neck cancer surgery: a systematic review. Head Neck. 2016;38(9):1421-1427.

4.    Hoverman JR, Cartwright TH, Patt DA, et al. Pathways, outcomes, and costs in colon cancer: retrospective evaluations in two distinct databases. J Oncol Pract. 2011;7(3 Suppl):52s-59s.

5.    Neubauer MA, Hoverman JR, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting. J Oncol Pract. 2010;6(1):12-18.

6.    Rotter T, Kinsman L, James EL, et al. Clinical pathways, effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;(3):CD006632.

7.    Zon RT, Frame JN, Neuss MN, et al. American Society of Clinical Oncology Policy Statement on Clinical Pathways in Oncology. J Oncol Pract. 2016;12(3):261-266.

8.    Fitch K, Pelizzari PM, Pyenson B. Cost drivers of cancer care: a retrospective analysis of Medicare and commercially insured population claim data 2004-2014. Community Oncology Alliance. http://www.communityoncology.org/pdfs/Trends-in-Cancer-Costs-White-Paper-FINAL-20160403.pdf. Accessed January 24, 2017.