Health care delivery is evolving as providers, payers and innovators strive to deliver effective, innovative and personalized medicines to patients in an affordable way. Unfortunately, change rarely happens without challenges. These challenges are especially evident in oncology, where the treatments are becoming more targeted to the individual patient, but also potentially more expensive.
As a result, insurers and providers are exploring ways to reduce the financial cost associated with treating cancer patients – both for the health care system and for the patient. Most of these efforts are focused on reducing the cost of prescription drugs, although according to 2013 Center for Medicare and Medicaid Services (CMS) figures, spending on prescription drugs accounts for around 9% of overall healthcare spending in the United States.
One specific mechanism to guide treatment decisions is called a clinical pathway, which is a tool for a provider to sequence the steps in a patient’s care based on evidence-based practice. Pathways have been implemented for decades and historically been created by the providers who use them. Yet, the level of interest among oncology practices in using them has grown in recent years, as a way for doctors, instead of payers, to lead improvements in quality that would counter the need for reductions in cumbersome and time consuming utilization management programs like step therapy and prior authorization.
Some health insurance companies are now looking at pathways as a way to contain cost while emphasizing quality. Skeptics are concerned that insurance companies might use clinical pathways to control drug utilization by limiting physician decision-making and restricting patients’ access to new state-of-the-art treatments for cancer and other chronic diseases. Of special concern to providers and patient advocates, at least one large insurance company is now paying physicians to prescribe therapies they preselected while denying coverage or requiring prior authorization when the physician opts for a different treatment based on the patient’s unique circumstances.
Another concern is that the process by which insurers develop clinical pathways may not be transparent – meaning patients may not know how decisions were made about which treatment options were given preferred status , whether their physician has a financial incentive to prescribe specific drugs, and who was involved in making these decisions.
So when the creation and implementation of pathways are driven by insurance companies rather than providers, what can this potentially mean for patients? Pathway programs created by insurance companies could harm patients if they delay needed care that may be considered “off-pathway,” impose unnecessary costs on the health system, waste providers’ time, effort and resources and lead to higher physician fees, and potentially remove treatment decisions from the hands of the physician and patient.
NPAF believes that pathways can be designed in a transparent way that supports personalized care and clinical judgment, but they also can be used to impose cookie cutter approaches that emphasize cost containment. Based on the expertise of NPAF’s Scientific Advisory Committee in reviewing the use of clinical pathways and nearly 20 years of experience helping patients overcome administrative and financial barriers to care through Patient Advocate Foundation (NPAF’s sister organization), NPAF has published a white paper and a policy blueprint for the establishment of core standards for all clinical pathways. You can view our specific recommendations and the full text of the white paper on the NPAF website. If you have any questions, please contact Lisa Hughes.
Alan Balch, Ph.D., is CEO of the Patient Advocate Foundation and National Patient Advocate Foundation (NPAF). NPAF is a national non-profit organization providing the patient voice in improving access to, and reimbursement for, recommended healthcare through regulatory and legislative reform at the state and federal levels. NPAF translates the experience of millions of patients who have been helped by our companion organization, Patient Advocate Foundation, which provides professional case management services to individuals facing barriers to healthcare access for chronic and disabling disease, medical debt crisis and employment-related issues at no cost.
