Clinical Pathways May Factor into ACO Reimbursement Strategies

Clinical pathway programs in oncology will be utilized with more frequency in the coming years and may be instrumental in changing prescribing behavior, according to researchers from Decision Resources.

The adoption of clinical pathways in oncology has the potential to streamline care. Breast cancer, colorectal cancer, and non small—cell lung cancer appear to be the conditions that are the current priorities for pathway programs, according to a new report from Decision Resources entitled, “Impact of Payer-Imposed Strategies on Market Access in Oncology: Clinical Pathways, Accountable Care Organization Contracting, Specialty Pharmacy, and the Evolution of the Buy and Bill Model.”

According to the report, 21% of surveyed managed care organization (MCO) pharmacy directors noted they already have a pathways program, whereas 37% say they plan to implement a pathways program within the next 12 months. The survey included data and responses from oncologists and pharmacy directors.

Although the pharmacy directors involved in the survey pointed to the cost savings that come with the adoption of clinical pathways, 34% of oncologists said that clinical pathways have narrowed the range of drugs they can prescribe. Although some critics are worried that pathways could potentially limit a prescriber’s drug choice, Roy Moore, product manager at Decision Resources, told Specialty Pharmacy Times that physicians aren’t currently being prevented from prescribing their favored drug, as they did not report “much difference in what’s permitted in the pathway and their preferred drugs for breast and colorectal cancer.” Pharmacy directors, on the other hand, suggest that MCOs want to craft these pathways themselves, and as a result, these programs “will likely be more restrictive going forward.” Over time, Moore added, pathways “will become uniformly more restrictive, as MCOs use the pathways as a way to extract better pricing from drug marketers.”

Moore says that it appears pharmacogenomic testing may be a crucial first step before a patient is assigned a pathway. He noted that the cancer population that was most commonly targetedn by oncologists and pharmacy directors was HER2+ breast cancer. “That likely reflects the availability of HER2 testing and Herceptin’s role in treating these patients,” he explained. “As more tests are developed for other cancers, expect them to be worked into the pathways.”

Moore believes that expensive branded therapies that are not approved for pathway inclusion may be at a disadvantage, especially since the cost and efficacy of each medication will be compared with its competitors by the oncologists, MCOs, and third-party vendors in charge of developing these pathways.

Authors of the report also concluded that physicians likely use specialty pharmacies “because of the benefit it provides them;” less than one-fifth of oncologists said their reason for using specialty pharmacy was based on an MCO mandate.

Moore admits that the pathways are not yet fully formed, and like biosimilar adoption, it may take more time and federal guidance to adequately craft the action plan for their use. “There are some early adopters who took the lead on this in recent years, but we’re just now starting to see more rapid uptake,” he said. “The fact that some MCOs are experimenting with pathways outside of oncology show that payers view this strategy as one that could change prescribing behavior.”