Evidence-Based Guidelines/Pathways Critical for Value-Based Benefit Design in Oncology

VBCC - July 2012, Volume 3, No 5 - AVBCC Annual Conference
Caroline Helwick

Houston, TX—There is no question that evidence-based guidelines and pathways are critical to the success of value-based oncology, but not all stakeholders have an equal voice, said Craig Deligdish, MD, Chief Medical Officer at Oncology Resource Networks of America at the Second Annual Meeting of the Association for Value-Based Cancer Care. The goals inherent in value-based oncology benefit programs include:

  • Improving outcomes
  • Enhancing efficiency for practices and health plans
  • Reducing the cost of care for practices and health plans
  • Simplifying and obviating the prior authorization process
  • Reducing the cost of care at the end of life
  • Improving care, with a focus on value, outcomes, and fiscal predictability
  • Sustaining community-based care.

“Clearly, we want to improve outcomes and we want to reduce costs, but at the same time we need to think about the patients who are often not represented in meetings such as this,” he said.

“The question is, what does the patient have to say about this?” Dr Deligdish continued. “One day, we may all be patients.”

The other participant often absent in these conversations, he added, is the government, “which is the elephant in the room.” The future of healthcare is being decided at the federal level through the healthcare reform legislation. And on the state level, changes are also occurring. Many states are unloading the responsibility for healthcare onto the commercial payers, moving healthcare from the traditional Medicaid programs to managed Medicaid. Such changes cannot be ignored, he said.

“We all know that chemotherapy is costly, and there have been tremendous advancements in cancer therapies. What we really need to recognize is that the cost of drugs is only about 20% to 23% of the overall spend for the treatment of a patient with cancer. This is a fraction of the $100 billion that is spent annually in the United States on cancer treatment alone,” Dr Deligdish said.

Evidence-Based Guidelines and Pathways: Features and Benefits

Evidence-based guidelines that have been issued by organizations such as the National Comprehensive Cancer Network and the American Society of Clinical Oncology help to ensure standards and predictability in patient care. The goal is not to institute “cookbook medicine” but to “provide some order to what many of you see as a very chaotic approach,” Dr Deligdish said.

Evidence-based guidelines offer an established process for reviewing pathways and ensuring appropriateness and relevance. They are used to create evidence-based pathways that aim to provide value, even enhanced value, and generally at a reduced cost. Pathways not only apply to chemotherapy but to supportive care, radiation therapy, molecular diagnostics, advanced illness, and other components of care.

The many benefits of evidencebased guidelines and pathways are clear: consistent delivery of appropriate and cost-effective care to patients, more predictable and lower patient care costs, lower administration expenses, less hassle for members and providers, less treatment delay, greater provider and health plan efficiency, and elimination of unnecessary services, according to Dr Deligdish.

Pathway Integration.
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Although pathway programs may appear relatively straightforward, their integration is complex, he noted (Figure). The challenge is to take the most promising pilot programs and demonstration projects and implement them in a scalable fashion that makes an impact, Dr Deligdish added.

Options for Payers

Payers have a variety of options for managing the overall value and cost of cancer treatment: primarily, pharmacy benefit managers, specialty pharmacy benefit managers, radiology benefit managers, oncology benefit managers, and health plans. As medicine becomes more complex and these programs become increasingly common, they become integrated into the hospital setting, where more care is now delivered.

“This is probably not the most efficient approach or the optimal place to receive treatment,” he maintained, “because treatment takes longer and costs 3 times as much as when delivered in the community.”

The overarching challenge, he said, is for all those who manage patient care and who aim to control costs to collaborate. “If stakeholders do not find a way to work together, inclusive of the government, we will be in a much worse situation than the one we have today, and at a much higher cost,” Dr Deligdish concluded.

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