On Sunday Oct 18th at the Oncology Clinical Pathways Congress, faculty members Robin T Zon, MD, FACP, FASCO, Gordon Kuntz, and Winston Wong, PharmD, gave a joint presentation of the preliminary findings of the Care Pathways Working Group. Initiated earlier this year and still ongoing, this group seeks to clearly identify challenges and actionable solutions for stakeholders as they face the evolving design and implementation of care pathways. Drs Zon, Wong, and Mr Kuntz lead the group as co-chairs.
The initiative is made up of 14 experts representing a wide variety of stakeholders, including clinical pathways leaders from academic, hospital, and community settings; professionals with experience in payer pathways; platform and operations consultants; employer group professionals; health policy and systems experts; patient advocacy; and comparative effectiveness researchers.
The overarching question behind this initiative is “What are the highest priority concerns related to care pathways and their implementation that need to be addressed in order to promote high-quality pathways that offer utility in payer negotiation and reduced costs/unnecessary variation in care while improving patient care?”
Thus far, the group has met twice on virtual conference calls, each spanning 2-3 hours to allow for discussion and debate of the key pain points in clinical pathways. Discussions have focused on the following three core areas in order to tackle such a big question: (1) revisiting pathways development and maintenance; (2) management and measurement; (3) and market impact/future directions.
Group members began by establishing common ground for discussion by agreeing upon a clear definition of what a “clinical pathway” is or should be. They also examined the various perspectives on and meanings of “value” in the health care ecosystem, noting that compromise and collaboration among stakeholders is needed. The question arose: “Do clinical pathways represent value, or are clinical pathways simply a tool that can be used to provide value-based care?”
For the first topic area, led by Dr Wong, members reviewed key elements of pathways, pathways development committees, and the role of patients in pathways. Members noted the significance of social determinants of health and debated how these factors could be integrated within a pathway. Regarding pathways committees, accountability and greater representation of both stakeholders and other service lines need to be integrated. And as far as patients in pathways, patient preferences (and patient-reported outcomes) were noted as lacking. Members also posed the idea of formal or informal use of pathways as a teaching tool for patients or for shared decision-making conversations.
Mr Kuntz took lead on the second topic area, in which members considered cost data availability beyond drug prices; pathway use as data collection and distribution tools; electronic medical record (EMR) and pathways integration; and pharmacogenetic testing. While the traditional paradigm for pathway creation has been to consider efficacy, toxicity, then cost, members voiced that affordability and costs of care cannot be ignored—financial toxicity and strain on the system is a real problem. Members asserted that we may be able to add some predictable costs to pathways, such as lab tests and companion diagnostics. They also noted that we could work with payers/Medicare to generate enough data on patients on particular regimens so that total cost data for “an average patient” can be given. On technology integration, members felt that pathways and EMR integration is the way forward, cutting back on software programs that physicians need to deal with daily. EMR vendors should be encouraged to follow merging integrated technology trends and pathways vendors ought to enable integration with old and new EMR systems. Finally, pharmacogenetic testing was noted as the perfect companion to pathways, as algorithms can help in identifying the appropriate timing, test, and actionable information.
Finally, Dr Zon spoke to the group’s ideas related to leveraging pathways with payers and their impact now and in the future on market dynamics. While we will always need clinicians to facilitate care, pathways can play a central role in streamlining and coordinating many pieces of care delivery. Among the elements pathways brings into harmony are data collection/analysis; educational support for providers; accountability of costs and quality for payers; greater value care for employers; and means of measuring and delivering high-value care within alternative payment models.
The Working Group aims to generate insights and solutions that are applicable within and beyond oncology to most care pathways. Complete findings of this project will be published as an article after consensus and action items are agreed upon by the group, likely by Spring 2021. This project is sponsored by Amgen.—Amanda Del Signore