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Video Transcript: Clinical Pathways and Other Cost-efficiency Initiatives Impacting Cancer Care (Part 2)

Webisode transcriptions completed by third-party vendor. AmerisourceBergen Specialty Group assumes no liability for the accuracy of the content.

Cost versus quality in cancer care. Technology's role in pathway implementation. Increased collaboration between payers and providers. How will providers capture and report data required by payers for clinical pathways? And how can the quality of care be sustained with less and less time available for patient visits? Join us to find out. “In the Know” starts now.

Hello and welcome to “In the Know,” your source for insight and analysis on the issues that matter to specialty pharma. I’m your host, Gina Clark.

Today, we host the second of our two-part discussion on clinical pathways and other payer issues affecting community oncology. We’ll explore the obstacles that stand in the way for pathway implementation and look at what the next year holds for cancer care from a reimbursement perspective.

Joining us is Lesli Lord, Executive Director for Oncology Physician Resource and Southwest Oncology Network. She is also an expert in practice management and reimbursement issues.

Thanks for being with us today, Lesli.

Lesli: You are welcome, thank you for having me.

Lesli, from the providers' perspective, what steps can be taken to ensure pathway compliance within the practice?

Lesli: Well, pathway compliance, that’s kind of a tricky point because you have a lot of physicians that want to treat the way they want to treat and it’s important to get buy-in from the physician community. That’s why it’s so important that it’s a physician-centric model, that it’s actually the physicians in that community that have developed the pathways, they’ve had a chance to review them, and they’ve been able to endorse them. So, when you get the physician buy-in from the community, and they’ve actually developed it, you’re going to see much more emphasis on the compliance because they are part of the solution, part of the process. And that’s why it’s so important to have them involved in that. Now, when you’re looking at the actual operational compliance of it, when they’re in the practice, there are many different ways you can make sure there is buy-in on the clinical level, where there are not only nurses, but your staffing and your billing people are all aware of that. If you have a technology component of it, then obviously you can have those pathways loaded into your EMR or any kind of technology you have in that practice, and then they know that if they have this practice, this patient coming in, this is the pathway they’re following and this is the reimbursement for that. So, that’s easy to put into your patient workflow, or your practice workflow, excuse me. Now, if you don’t have a technology solution in there, that’s a little bit more challenging, but it doesn’t mean that, you can’t do it. It just means that you have to have that pathway built into, let’s say, your super bill. Or for those who are handling PQRI, you’ll follow a lot of the same models you follow on that. So there could be, actually, a workflow or router in that patient file that shows, this is the pathway, this is the payer, and this is how it works. So it just has to be built into that workflow, for that patient and for that provider. So, it can be done, and you want to be sure that there can be compliance at a reasonable level, you don’t want to have compliance to a pathway at ninety five percent, because then you’re setting yourself up for failure. And you also want to make sure that in every pathway, you have clinical trials included in that. So if a patient does have a clinical trial pulled from any kind of analysis, you can be able to calculate what that is.

What are some common causes for significant deviation from established pathways, and what effect can this have on practice success?

Lesli: You need to take those into account when you’re looking at your compliance, you need to make sure that you have a reconciliation process in place, and that reconciliation process moves, then, those outliers from your calculation. You know the clinical trials that we talked about a couple of minutes ago, that was really important. You want to make sure that all the patients that can qualify for clinical trials don’t affect your compliance levels. Also, if you have a reconciliation process in place, where you can identify why a patient wasn’t on that pathway, if they can show the evidence, and the data supporting why it shouldn’t have been in the initial pathway, then that patient can be pulled from their calculations as well. There are ways you can set up your physician for success to be able to be compliant with that, and another tool to be able to do that, or strategy, is in the beginning, set your compliance a little bit lower, instead of setting eighty five percent to start, start at seventy-five percent compliance. And then, after three months, six months, bump it up as you go along. That way you’re setting yourself up for success for your calculations on this.    
 
You know, quality of care comes up quite a bit in the discussion around clinical pathways. How do providers and payers balance the quality versus cost discussion as they move forward with pathway development?

Lesli: Well, quality is elusive, who can find what that quality is, because obviously the payer has a different idea what quality is than maybe your provider has. So, when you look at that, the good thing about these pathways is that they’re all evidence based; you have something backing up, saying why you are doing what you’re doing. And by standardizing your care, that’s going to decrease the errors, that’s going to hopefully decrease the hospitalization rates because your errors aren’t going to be there. We find you have a standardization process in play, so quality is going to be improved obviously, if you can keep those patients out of the hospital. And then also if you have a process in place that you can keep these pathways identified, then it keeps everybody kind of moving in the same process. When they reach that end point, whether it’s end of life care or a different line of treatment, then regardless who that physician is, they have a path that they are going to follow and that’s very helpful for the payers, because then they can identify again that variability and if they can predict the variability, then they can somehow manage what their costs are going to be, and then the same on the side for the physicians. It’s nice to be able to know how you are going to be treating eighty to ninety percent of your patients. That can affect you dramatically when you are contracting with your manufacturers, when you’re looking at your par levels, when you’re ordering product, so all around it makes good business sense, but then also, it brings it back to the quality, reducing those errors, reducing hospitalization. Ultimately keeping a more steady cost for that patient care, which is obviously more helpful for the patient.   
 
Does this line of thinking extend to the controversial issue of end of life care, as well?

Lesli: It does, and you know that the end of life care is the Holy Grail for the payers and also for the providers, because it’s a very difficult situation. Most of our providers that I work with, they’re not comfortable with the end of life issue either. They continue to fight for that patient, and when you look at the end of life care, that really brings us back to that medical home concept. And you see a lot of medical home in the primary market, but what we’re trying to do in our defer markets is to develop an oncology medical home and that includes your end of life cares. So, if you can incorporate pathways, technology, end of life care, and then obviously the reporting aspect of it, then you can make a strong case to that payer, that patient belongs to the oncologist and it doesn’t need to be with the primary care doctor. And if we can do that, then we can negotiate more opportunities of case management fees to be able to handle that. We can look at the data on how it’s treated and then we have a better opportunity to make that case. Right now we can’t make the case because we don’t have the data backing us up. But the ultimate goal of these pathways is that first step to get us to that end goal of the medical home for that oncology patient.     

Technology like electronic medical records, e-prescribing and practice management systems clearly play a substantial role in pathway reporting. Can you discuss how practices are approaching this—especially those practices who may have the most need for the financial benefits of clinical pathways, but the fewest resources for new technology investment?

Lesli: Right, and the technology, I hate to say, is the most important part of this. We have our physicians who are incredibly bright, they can develop the pathways, they can find the data, and they can do all things on how to treat that patient. That’s not where we’re finding the biggest struggle here. What we have to prove to the payer, and also to the community at large, is that we can track it and that we can be able to identify what are those metrics to be able to say, what is quality? What is not? So it’s very important that that process has some kind of technology solution. For those that have the biggest practices management systems and EMRs, fabulous. They are already there. Except for those smaller practices, they have to have a solution. And that’s where they can partner with different companies in the industry that have that technology solution for them. If you look at ABSG and look at what they have with their different practice management tools, those can be implemented at a very low cost for the practices that they can comply with, that they can report, and that they can also, at the very end, aggregate it to be able to prove to the payer that not only clinically do we know what’s best, but we also know how to report it and monitor it, reconcile it, and at the very end, be able to show what’s the most effective cost of care for these patients.         
 
Outside of technology adoption, how will providers have to modify their workflow and coordinate with other providers to deliver the right data to payers and in the right way?

Lesli: It’s a little bit difficult because a lot of the times these practices feel like they’re in competition, and obviously they are, they have their markets, they’re all trying to fill their space, and keep their practices a float. We need to change that mentality of it being a competition. We’ve got to look up and say, “Our survival for community oncology is at stake here, especially for smaller practices and the access to care is a big issue on that.” So we’ve got to get over that hurdle of saying, “I don’t want to work with practice B down the street because I don’t want them to know what I’m doing, or because I’m getting paid, or anything like that.” That’s why we go into it with an attitude of quality. We’re going into it for a quality program, that’s what these payers are trying to get at, and we can get through that if you say, “Together practice A, practice B, practice C, they are all going to use these pathways that we agree are clinically good medicine.” And once you’re going to get them to agree on that, then you move to the next step of saying, “We’re not going to know what your practice is doing and some other practices aren’t going to know what each individual group is doing. We’re going to look at this as an aggregate and know quality care in the state of Oklahoma, Texas, or Michigan.” And it’s proven to be very effective with the payer, you can say to them, “This is how all the cancer patients are going to be treated in the city or the state, excuse me, of Michigan. And as a result, the payers benefit, the practices benefit, and the patients benefit, and the pharmaceutical communities’ benefit. It’s good business and good quality care for our patients.”            
 
Lesli, what role or responsibility do physician organizations, like national and regional medical associations, have in providing education and guidance to their members regarding issues like these? In what ways can these associations work more closely with payers and pharma to create more collaborative relationships?

Lesli: Well, that’s a great question because they’re in the best position, these state and regional groups, to be able to have the greatest amount of impact. Because we are seeing more success on a state or regional level, when you’re looking at payer programs like this, so they have the opportunity that they are already working with their provider members to be able to provide them educations, so they have the ability to get more people together and educate them. How do you develop a pathway program? You look at other states that have been able to do it, like in Michigan or you look at other areas like North Carolina, or at other states that have been very successful in collaborating or working towards a solution. So these state organizations have a great opportunity to not only look at the advocacy arm and the education arm, they can also help them get to the next point of developing that payer program, where it’s not collusive, nothing like that, it’s quality initiative so that they can all come together under a general platform without it being centered on one or two practices.     

OK, crystal ball time: At this point next year, how much traction will clinical pathways have gained in the oncology market? Will the obstacles for rollout have changed? And will practices and payers see enough benefit to eliminate some of the distrust that has historically existed between the two camps?

Lesli: Crystal ball, it’s a reality. Pathways are going to be here and it doesn’t mean it’s the end game. Like we discussed earlier, the end game is hopefully the oncology medical home, but it comes to the matter of these physicians, they have to develop their own pathway program or a third party disease management firm is going to do it for them. I mean cancer is on the table now, NCCN released a report in January of last year, and the title of that report was “Cancer is on the Table”. Historically payers have stayed away from really getting involved in the disease management of oncology, but now with the raise in costs, with the biologics involved, they are in the huge variability, they are now saying, we have to address this. So if the provider community can’t come to them with a solution, then they are going to find an independent third party or a disease management company to do it for them. So that’s why we are talking to the providers, we’re there to say, “Take this opportunity to take control over what you’re doing in your state, otherwise that’s going to be taken away from you.”

Lesli, This has certainly been an eye-opening discussion. Thank you again for being with us.

Lesli: You’re welcome.

And thank you for joining us—we’ll be back soon with another, all-new webisode. Until then, if it’s on your mind, it’s In the Know.

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