Do Clinical Pathways Improve the Value of Cancer Care?

Published in Oncology Times: 25 August 2009 - Volume 31 - Issue 16 - p 28

Cancer Care Northwest (CCNW), a 16-physician practice in Spokane, Washington, has been working with the area's largest insurer, Premera Blue Cross, for six years to find a better way to deliver and pay for cancer care.

Through its Foundations of Quality program, CCNW has undertaken many quality initiatives and received bonus payments from Premera in return. One of the initiatives is the implementation of clinical pathways for CCNW patients.

We have done a variety of things, but pathways have assumed a greater importance over the years because we have recognized that, first of all, they are doable and secondly, they really do decrease variation, said CCNW partner Bruce A. Cutter. Providing they are done correctly, they are a push towards value-based health care.

More than 3,200 patients have been treated on CCNW's clinical pathways since the program began in 2005. During that time, only 8.6% of patients were treated off pathway for a clinical reason that was documented, peer-reviewed, and approved according to the pathways protocols.

The practice currently uses 19 pathways-15 medical oncology pathways, three radiation oncology pathways, and an ovarian cancer pathway that incorporates surgery and chemotherapy. A surgical pathway for melanoma is currently in development, as well as multidisciplinary pathways for esophageal and rectal cancers that incorporate all three disciplines: surgery, radiation oncology, and medical oncology.

Dr. Cutter explained how CCNW's work may identify a way toward health care system reform.

Why have pathways become more significant to your practice?
Bruce A. Cutter, MD: There are ever more studies illustrating the importance of unexplained variation in both quality and costs in the US health care system. Pathways, in our mind, are probably the single most important tool for dealing with that unexplained variation.

How has your pathways program changed since its inception?
Dr. Cutter: The pathways to date have been mostly medical oncology-focused, but we're increasingly working on pathways for the radiation oncology component of care and also for the surgical component. We then take those separate efforts and merge them together into a true multidisciplinary pathway.

This is harder than I initially thought it would be, and more important than I initially thought. We always say that we are an integrated group and we're providing integrated, coordinated cancer care. But this effort really stimulates a degree of collaboration and communication with each other beyond what we have accomplished in the past.

Going through these pathways and committing ourselves to following them and being held accountable for the results in a multidisciplinary fashion really takes this effort to the next level. I view that as a major event.

Does Premera pay you for adhering to clinical pathways?
Dr. Cutter: We get paid just like we always have, but we receive a premium over the rest of the market because of our various quality efforts. Also, there is a pool of money that is set aside, and our receiving that money is strictly dependent on our meeting or exceeding the objectives and results for clinical quality indicators that we both agree upon at the beginning of the year.

Does the use of clinical pathways reduce the cost of care for Premera or your patients?
Dr. Cutter: The hypothesis is that doing various things that constitute quality-for example, the use of clinical pathways, as well as measuring clinical metrics and patient satisfaction-will provide at least the same, if not improved, quality outcomes at less cost. That hypothesis remains to be proven.

Initially there was a certain leap of faith by both organizations, with both being willing to make the effort and take the risk involved with this program without yet having proof of the value hypothesis.

We have embarked on a study, using claims-based data, to determine whether there is cost savings associated with following our clinical pathways. We are trying to provide evidence for or against the hypothesis that standardization of care is value-enhancing and cost-effective care that decreases not just the medical oncology cost, but the total system cost of treating cancer. We hope to have some good data by October.

What are the implications for this study?
Dr. Cutter: If we can provide support for the hypothesis that quality and clinical pathways enhance value, it will be of major significance to the healthcare reform debate.

There is good data about the lack of association between higher costs [of health care] and higher quality. If you're trying to reform a system by improving quality while lowering costs, the question becomes, How do we actually do this? The use of pathways is certainly one way, and a potentially important way, by which one might actually undertake reform.