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Clinical Pathways and the Oncology Medical Home: First Steps to Value-Based Patient Care

February 2016 Vol 9, Special Issue: Payers' Perspectives in Oncology

With $137 billion and growing spent on treatment in the US healthcare annually, cancer care delivery poses a significant challenge. At a special session at ASH 2015 on new payment models, Michael Kolodziej, MD, National Medical Director for Oncology Solutions at Aetna, discussed pathways and the medical home as transitional solutions to value in cancer care.

Wasteful Care in Oncology

“I think everyone in this room knows that care is not delivered optimally, and payers actually have no idea whether providers are doing a good job or not,” said Dr Kolodziej. “A lot of what we do is just not value added; it’s duplicative, and it’s futile. I think practices will need to embrace process improvement in order to succeed, and I believe data are critical to the evolution of cancer care delivery.”

According to Dr Kolodziej, less than 1% of the US population has an oncology-related diagnosis, but cancer care accounts for 11% of the total healthcare expenditures. The bulk of these costs are driven by care delivered during the diagnosis and end-of-life phases, a fact that was not lost on the hematologists in the audience.

“Hospice utilization for hematologic malignancies is the worst across the cancer spectrum,” Dr Kolodziej said. “A third of patients spend time in the ICU [intensive care unit] in the last month of life.”

In addition, despite the almost exponential increase in the cost of drugs, Dr Kolodziej emphasized a lack of correlation with improved outcomes.

“There is no obvious relationship between cost and quality,” he said, “and it’s not just the cost of drugs. The healthcare system produces $750 billion in yearly waste. Thirty percent of health spending is waste.”

Insurance companies’ response to the crisis has been to pay providers less and manage more—in the form of prior authorization—but this is not the answer, said Dr Kolodziej.

“The impact has been small, and it has driven every doctor in America crazy. Obviously, we’ve got to do something different,” he emphasized.

Pathways Save Money, Reduce Variability

According to Dr Kolodziej, trying to attain the best possible outcomes at a fair cost, or bringing value into the equation, is the solution, and pathways represent the logical first step.

“Every oncologist in America thinks he’s better than average,” said Dr Kolodziej, “but not every oncologist has developed the process around limiting variability.”

Such a process, he said, entails actually evaluating the evidence and operationalizing it, starting at the point of care, measuring performance, and striving to improve.

“All the pathway companies do the same thing,” Dr Kolodziej explained. “They look at what’s covered, NCCN (National Comprehensive Cancer Network) guidelines, basically; they look at toxicity, and then they look at cost. Cost only enters into it about 10% of the time.”

With this information, a portal is then designed for use by providers. Although this may sound simple in theory, building an effective portal is difficult, which is why Aetna, for example, has chosen to use a vendor, he said.

The mission, however, remains easy to understand—getting the right care to the right patient at the right time. And if you ask Dr Kolodziej, it is working with the use of pathways. One study by Aetna showed a 43% relative improvement in adherence to evidence-based treatment selection using pathways.

“Payers love pathways because they save money and reduce variability,” he said. “A lot of you know that I’m a big fan of process improvement, and pathways are the first step toward understanding the idea of process improvement.”

“Pathways are scaffolding,” he added. “They are a means of structuring the way providers think about managing patients….It is a format by which [providers] can start thinking about innovation.”

Patient-Centered Medical Home

Another step toward finding the solution is the patient-centered medical home in oncology, a setting that facilitates partnerships between individual patients and their personal physicians, and, when appropriate, the patients’ family.

“If you had to sign up for cancer,” said Dr Kolodziej, “this is what you would think you were signing up for—a medical home relationship.” He added, “Heretofore, there really hasn’t been an oncology medical home, but there’s going to be one.”

The principles of the patient-centered medical home involve:

  • A personal physician. Each patient has an ongoing relationship with a personal physician, who leads a team of individuals that takes responsibility for the ongoing care of patients
  • Care is coordinated across all elements of the healthcare system
  • Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication
  • Payment recognizes the added value provided to patients who have a patient-centered medical home.

“In short,” said Dr Kolodziej, “the medical home is about team-based care and evidenced-based care and providing good access to patients—people answering your questions and your phone calls. And it’s about rewarding physicians if they do a good job.”

Ultimately, he said, pathways and the medical home may be the first steps, but they are not the total answer.

“All this stuff is transitional, because we will get to episode-based payment,” Dr Kolodziej concluded. “Care occurs in discreet episodes, there’s variability, and bundling has worked in other conditions, which leads payers to believe it will work here.”

“But we also need each other,” he added. “The path forward involves partnerships.”

Last modified: August 30, 2021