The Future of Clinical Pathways

Conversations and healthy debate about issues facing our industry and the health care system are critical to addressing some of today’s challenges and opportunities. The Catalyst welcomes guest contributors including patients, stakeholders, innovators and others to share their perspectives and point of view. Like in our Conversations series,  views represented here may not be those of PhRMA, though they are no less key to a healthy dialogue on issues in health care today. 

To continue the dialogue about clinical pathways and what they mean for treatment options, we’re pleased to host a guest blog from Eric Hargis, chief executive officer, Colon Cancer Alliance. 

Utilization of clinical pathways, in which an individual’s treatment follows a defined protocol, can help ensure patients receive the best possible care based on the most recent scientific data. However, clinical pathways can institutionalize a “cookie cutter” approach instead of personalized medicine, as well as limit treatment options in order to cut costs. So, which of these will be the future for clinical pathways?

With so many new care and delivery models being considered, let’s be clear on definitions.  Networks of clinicians such as the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) produce practice guidelines. These are recommendations based on a systematic review of evidence and assessment of the benefits and harms of alternative treatments. Practice guidelines tend to be broad in nature. A clinical pathway essentially translates practice guidelines into specific, standard care for a defined patient population. In other words, it gives your doctor a defined protocol for your care.

There is solid evidence that appropriate use of clinical pathways can improve patient outcomes. Cancer is a complex and difficult disease to treat and new data for cancer care is constantly emerging. Particularly for oncologists who treat many forms of cancer, it is a challenge to stay abreast of state of the art care for multiple cancers. Clinical pathways can serve as a conduit for this information, be a great resource to clinicians and a benefit to their patients.

Clinical pathways are developed by both providers and payers, and there are a lot of them. This raises the question: If there is a single best protocol for a specific patient group, why so many different pathways? The reason: there is no one best protocol and some variation is needed, especially as care becomes increasingly personalized. First, it is difficult to make head-to-head comparisons of different medications, and a range of factors, such as genetic variation, differences in clinical characteristics, and co-morbidities will all factor in to what might be best for an individual patient. Beyond the medical aspects, the hopes, dreams and lives of patients must be part of the treatment equation. For example, a patient who uses his or her hands for their job, such as a musician, would put a premium on avoiding neuropathy and may opt to deviate from the pathway due to this treatment goal. Some estimate that approximately 80 percent of patients benefit from adherence to a pathway and 20 percent need some variation, but even that can vary across cancers.

Many payers now incentivize the use of their clinical pathway and it is here that the path can become slippery if incentives are not structured carefully.  Pathway incentives can be a positive force to improve care when the compensation is tied to patient outcomes. In other words, the provider does better if the patient does better. If, however, compensation is tied only to following the protocol, then the provider is incentivized not to deviate and makes more money by using a cookie cutter treatment plan, even if it is not the best plan for the patient. This type of incentive is the antithesis of personalized medicine.

And there are other issues at hand. To what degree should cost be considered in the protocol? Is a provider incentivized to limit choice in order to save money? What about the number of clinical pathways?  An oncologist’s practice group may have one clinical pathway, and a health insurance company may have another.  A clinician could treat five patients with the same cancer but have five different clinical pathways to navigate. 

Clinical pathways can be valuable, but the future is uncertain. As both providers and payers utilize pathways, it is important that they serve as a resource for clinicians and not a restriction on the care a patient receives. If there are incentives for using a pathway then the incentives must relate to improvements in patient care and not blind compliance with a set of rules. Above all, let’s avoid the day that the insurance company logo on a chart is what defines cancer care.

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