Pathways-Based Cancer Care Reduces Hospitalizations, Care Variation, and Costs

VBCC - December 2014, Vol 5, No 10 - AVBCC 2014 4th Annual Conference
Wayne Kuznar

Los Angeles, CA—An oncology pathways-based decision-support tool in­stituted as a collaboration between a payer, oncologists, and other network providers can modify physician behavior that results in cost-savings and reductions in cancer-related inpatient admissions, according to Bruce Feinberg, DO, Vice President and Chief Medical Officer at Cardinal Health Specialty Solutions, Dublin, OH.

At his presentation at the Fourth Annual Conference of the Association for Value-Based Cancer Care, Dr Feinberg debunked frequently recommended solutions to the crisis in cancer care delivery, including “value not volume” payment models, strategies to enhance physician competency, patient decision-sharing efforts, and health information technology upgrades.

Social and Economic Pressures
“The evidence is…quite clear that the shifting site of care could be doubling cost of care in certain populations like cancer care. But we have a fragmented system, and so there may not be any one stakeholder who is able to really do what’s necessary to prevent that shift in site of care, as we saw with the shift in the COA [Community Oncology Association] map earlier with the migration of oncology. Which probably now is somewhere from 80% of oncology care being delivered in the community, to about 60% being delivered in the community in a fee for service private oncology practice,” said Dr Feinberg.

In addition to the shifting site of care, rising drug costs, longer treatment cycles as a result of life-threatening diseases becoming chronic diseases, and innovation in drug therapies that enable us to treat patients we were unable to treat before are stressing cancer care and the healthcare system, said Dr Feinberg. “The end result of this is social, scientific and economic pressures on cancer care, and all health cares, have stressed the system,” he said.

Many proposed solutions to the crisis in cancer care delivery have not been effective, he said. In general, evidence does not seem to be driving physician behavior. Dr Feinberg provided the example of the divergence in the use of Oncotype DX testing by oncologists who treat patients with breast cancer. Appropriate patients for Oncotype DX are those with T1, T2, N0, estrogen receptor–positive, or HER2-negative disease.

In a practice of 41 physicians, the percentage of eligible patients tested by physicians who had ≥10 eligible patients for Oncotype DX testing ranged from 0% to 71%. “We’re not dealing with mathematics when we deal with the science of medicine; we’re dealing with mostly shades of grey, and very little black and white,” Dr Feinberg said.

Clinical Pathways Change Oncologists’ Behavior
Reimbursement methodology may not be the answer to changing behavior, he said. Dr Feinberg’s group conducted a retrospective analysis of a pilot program that offered physicians in an oncology medical home a reimbursement model that shifted the source of revenue from drug reimbursement margin to professional charges for cognitive services. The team observed no significant change in physician behavior by the shift, including no change in chemotherapy prescribing and no increase in the use of generic regimens compared with a matched control group.

Pathways that eliminate unnecessary medical interventions would decrease drug and nondrug expenses for patients who are managed based on pathways, with no negative effect on survival. In a study by Temel and colleagues (N Engl J Med. 2010;363:733-742), an early palliative care pathway integrated with standard oncologic care for patients with lung cancer improved quality of life and survival despite less aggressive treatment compared with standard cancer care alone.

Such a strategy has not been embraced, as evidenced by the uniformly substandard use of hospice care in Medicare beneficiaries with cancer. In the final month of life, only approximately 50% of patients with cancer are enrolled in hospice, and the ones who are spend only 8 days in hospice.

Overall, 66% of patients with cancer are hospitalized in their last month of life, and 25% are admitted to an intensive care unit in the final month of life.

Cardinal Health Pathways: Improved Outcomes, Reduced Costs
To mitigate the more relevant behavioral and cultural issues that preclude effective cancer care, Dr Feinberg showcased Cardinal Health pathways (PathWare), which are digital pathways-based decision-support tools. The software helps oncologists choose evidence-based, cost-effective therapies for patients with common cancers, as well as implement timely end-of-life care. The tool is user-friendly and can be navigated in <2 minutes.

The key to changing providers’ behavior is to evaluate pathways compliance on the 20% of diagnoses responsible for 80% of the cancer care costs, Dr Feinberg said, and to focus on behaviors with the greatest impact on cost and quality.

“What we’ve seen in our claims data is that two thirds of the [drug] regimens that are given in the third line of cancer care are complex,” he said. “Yet, every bit of evidence says single agent sequential is the way to go, because all you’re doing with complex regimens is incurring more toxicity that fragile patients cannot tolerate, and putting them in the emergency department and in the hospital.”

The payer-supported oncology pathways programs for breast, colon, and lung cancer have been evaluated with 5 payers and have realized a 15% decrease in the cost of cancer care in the first year, along with a 7% reduction in hospitalizations and emergency department visits.

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