Gordon Kuntz is a health care consultant and strategic advisor with over 30 years’ experience in a multitude of health care settings, working with payers and providers, and in technology and strategy. He began his involvement with oncology care pathways in 2004 as a consultant with US Oncology as they were deploying Level 1 pathways. He subsequently led payer strategy with ION Solutions, a division of AmerisourceBergen, where he gained familiarity with many other pathways vendors, especially in the context of the oncology medical home model. As senior director of strategy for Via Oncology, he deepened his knowledge of the pathway development process, physician adoption, and how both impact cancer center strategies. Mr Kuntz now provides support in strategy and product design as well as assistance in navigating the cancer care ecosystem to established and emerging companies.
Pathways have come a long way since 2004 when initial forays into pathway development were paper-based and offered limited guidance outside of breast, lung, and colorectal cancers. The tools available at that time lacked the subtlety and nuance that current pathways offer.
Development of additional disease coverage emerged rapidly, and automated tools emerged in 2007/2008. By about 2015/2016, some tools—such as Via Pathways, Moffitt Pathways, and McKesson’s Clear Value Plus tool—incorporated treatment recommendations for more than 90% of cancer by disease incidence. Payers began to recognize that pathways offered a measure of quality, which helped drive adoption and the growth of payer- and provider-initiated pathways.1 US Oncology’s Innovent Oncology, the Michigan Medical Home Demonstration Project, and Aetna’s New Jersey pathways pilot all featured the use of evidence-based medicine as a condition for participation.2-4
Over the years, pathways vendors have come and gone, or they have progressively evolved in accordance with technology and user feedback. Via Oncology (now Elsevier ClinicalPath), US Oncology’s Level 1 Pathways, eviti, and New Century Health have all survived in some form.5,6 ION Solutions partnered with Novologix for a time, which was then sold to CVS, and has re-emerged as a prior authorization tool.7 In recent years, we have seen more consolidation and acquisition, which has injected much-needed resources into the segment.
With all of this change, what lies ahead? This column will consider a few angles: what we should not expect to happen anytime soon, what I expect to happen in the next couple years, and what my hope is for the future of oncology pathways.
Please note that all opinions, predictions, and prognostications are my own. In considering how pathway programs may evolve further in the years ahead, I have relied solely on my own experience with pathways over the past 15 years in what I see as deficits to be corrected or forces that may inhibit or promote future changes.
What Not to Expect
Before moving into an exploration of the direction I expect and hope pathways to take, it is important to take a moment to discuss what is not likely to happen. These future scenarios are unlikely to happen due to economic limitations and structural norms that are so ingrained as to be definitional in our current concept of “oncology pathways.”
It is unlikely that we will see a significant investment in broader disease coverage. Having reached the 95% threshold, most major pathways vendors have reached a point of diminishing returns. Developing and maintaining new disease pathways is a labor-intensive and expensive proposition. Many small-population diseases lack easily described standards of care and rely on clinical trials, so the utility of pathways is limited. Frankly, maintaining the pathways already developed is a very significant effort for anyone who regularly updates their pathways.
Similarly, it is highly unlikely that we will see programs that reflect radically different models of pathway determination. The efficacy/toxicity/cost model, coupled with targeting pathways for 80% of patients, is so ingrained in the oncology psyche that it will be very difficult for a re-imagining of pathways to take hold. That said, there is room for adjustments to this model to better account for important considerations lacking in this historical approach.
Along the same lines, the industry has seen a few attempts to incorporate the concept of value into the pathways themselves. This is especially problematic when trying to define value in terms of clinical outcomes (eg, defining value as outcomes over cost). The United States would seem to lack the political will to negotiate an outcomes-based, independent definition of clinical value. For example, the 2010 debate about the Affordable Care Act (ACA) quickly devolved into charges that the ACA would cause there to be bureaucratic “death panels” to decide who would live and who would die.8 We see this trend in the debate about health care in the current election cycle as well, with some voices charging “socialism” when there is a policy proposal about expanding health care coverage to all Americans. Imagine the furor of suggesting that quality-adjusted life year should be a factor in determining treatment recommendations.