Advancements in Pathways Since Year 1 of the Oncology Clinical Pathways Congress
An interview with Journal of Clinical Pathways editor-in-chief Winston Wong, PharmD, president, W-Squared Group, Longboat Key, FL.
Dr Wong kicked off the Congress on October 11, 2019, with a presentation of findings from the Journal of Clinical Pathways (JCP) Oncology Clinical Pathways Survey of real-world pathways stakeholders regarding the current landscape of pathways use in oncology practice. He provided commentary around the results and explained how Congress presentations would address challenges identified in the survey.
Could you provide a brief comment on this year’s Oncology Clinical Pathway Congress? In your opinion, what were some of the most notable themes or lessons you gleaned from the Congress?
Dr Wong: This is the fourth year for the Congress, and each year after attending, I seem to really get re energized and more passionate about the concept of clinical pathways. What I gleaned as major advances in this year’s conference is that, as I reflect over the past 4 years, I actually see clinical pathways continuing to evolve from a more comprehensive standpoint.
I remember the focus of the first year was basically just talking about treatment decision support. Now we are talking about greater comprehensiveness, treatments like surgical oncology, radiation oncology, as well as bringing in the patient aspect.
In his presentations each year, Alan Balch, PhD, CEO of the National Patient Advocate Foundation, always expands my thinking more and more about the patient aspect. When we start talking about personalized treatment pathways, I usually think more toward the diagnostics and personalized care. Bringing in all the other patient factors, like travel time to appointments, potential loss of work, and adherence, definitely is a new dimension for pathway consideration.
In light of these elements and others, it is exciting for me to see this continued evolution toward more comprehensive, personalized pathways. In addition, seeing the American Association for Cancer Research Project Genomics Evidence Neoplasia Information Exchange (GENIE) presentation about the genomic analysis was fascinating, which I think ultimately is going to lead to true, personalized treatments and personalized medicine in the future as well as even leading to more drug development.
Along with the Genie presentation, were there any other sessions, presentations, or even informal conversations that stood out to you that you benefited from?
Dr Wong: Thinking back to the first year, one of the major barriers that we have always seen—and even I saw it early on when I started getting into pathways some 12 years ago—is electronic accessibility. The integration of the pathways into the electronic medical record is a challenge, so seeing what Moffitt has done, seeing what Dana Farber has done in building their own systems, is excellent. They both succeeded in getting the engagement of their physicians to buy into putting a pathway together and then internally developing their own system for accessibility, which is truly remarkable. If I compare today to what was there 4 years ago, to what was there 10 years ago, I see major advancements.
Electronic integration is definitely something that needs to occur on a broad scale in the future to enable clinical pathways to become a standard of practice. Ultimately, as we start talking about the value-based benefit or contracting benefit designs for patients from payers, the reimbursement to these practices is going to be really pared down. They will need tools in place to help them become efficient, not only in treatment and workflow, but from a financial perspective as well.
The use of clinical pathways—comprehensive clinical pathways—is going to be a necessity for practices to be able to survive in the alternative payment models on the horizon.
Do you believe that more and more practices, especially on the academic side, will heed the model set by Moffitt and Dana Farber and move toward their own in-house pathways or comprehensive pathway programs? Or, do you believe that the resource barriers to doing so will keep more practices from moving in that direction?
Dr Wong: As I mentioned in the State of Clinical Pathways presentation talking about the results of the clinical pathways benchmarking survey, a recent study looking at the level of penetration of clinical pathways in small to medium independent cancer centers and practices brought to light that clinical pathway utilization was minimal. It was found that this was partly due to the inability to engage the physician. But the primary barrier is because it is cost prohibitive for these practices to put in the systems that are needed to go and truly make the clinical pathway process or program successful. I think in-house pathways are going to be mostly driven by the academic centers such as the Moffitts and the Dana Farbers.
However, that is not a bad thing because ultimately what we have been seeing over the past 10 years is a reduction in community independent practice and a movement into the more integrated delivery systems.
What we did find in that same study completed earlier this year is that, as they are getting integrated into the health systems, the health systems are now taking their clinical pathway programs or platforms, and extending them out to the small practices. The penetration of clinical pathways is growing, but it is growing by consolidation as opposed to adoption.
How do you anticipate the conversation of pathways changing in the next year?
Dr Wong: If I had to forecast, I would probably suggest two different directions. First, I would predict that more real-world evidence will be integrated into care and pathways to make pathways more personalized. We saw quite a few presentations that were talking about “real-world evidence.” For example, Dr Balch brought in real-world evidence from the patient perspective. Genie is bringing in the real-world perspective from a genomic diagnostic aspect. You have Moffitt and Dana Farber bringing in their perspective in bringing in the patient experience of care. And Roswell brought in a patient education piece. As we bring in more patient and real-world aspects of care, increasing the comprehensiveness of a clinical pathway will then make it a tool that goes far beyond that of physician decision support.
The second focus, that I would anticipate seeing in future years is that we will have more alternative payment models kicking in. For example, we have Oncology Care Model 2.0 coming in. We are probably going to hear a little more about how the practices are interacting with that and utilizing clinical pathways as a tool for success. We heard a comment from Robin Zon, MD, FACP, about how her practice, utilizing clinical pathways, is now going out to the large employers directly.
Of course, there are some barriers there, especially from a payer perspective, but I think that is really the way we are going to see large employers go, because they are concerned about their oncology cost. Their perception is that payers are not managing oncology well.
Large employers would be willing to partner up with a local or regional oncology practice that is showing and demonstrating that they can provide quality care at a lower cost, which is probably going to be driven by the use of clinical pathways. While payers (insurerers), as we know them today, can be a barrier to this direct carveout model, there are options available as possible solutions. A possible solution that comes to mind is for large employers or coalitions to utilize a third-party administrator. Many of the third-party adminstrators already have clinically integration networks in place that would have the capability to carve out a specific specialty. Clinical pathways will allow an oncology practice to become more competitive, providing quality health care services and a positive patient experience at a controlled cost. Another way to look at this is that the use of clinical pathways will allow an oncology practice to complete and negotiate value-based contracts directly with the self-funded employer.