"What has been missing is the patient's perspective," says one industry consultant.
The future of clinical pathways is patient-centric: an approach that balances the long-standing focus on cost-effectiveness with personalized medicine choices, defined by patients and providers, to deliver results across the value chain. “What has been missing is the patient’s perspective,” says Winston Wong, PharmD. Wong—whose career has arced from health plan pharmaceutical executive to industry consultant and editor-in-chief of the Journal of Clinical Pathways (JCP)—states that has been the field’s most significant shift since 2015. This perspective includes many facets: financial, treatment tolerance, caregiver support, and a holistic view of the person receiving treatment.
Definitions and foundations
Many factors can and must contribute to patient-centered clinical pathways, many linked to the very dynamics that will help the healthcare industry shift from volume- to value-based care (e.g., provider integration, innovation, social determinants of health). By definition, a clinical pathway is an evidence-based treatment plan. Wong adds to this definition the “balance of efficacy, tolerability, and affordability [that] lead to the set of preferred treatment options,” with accountability for following the pathway being critical.
Built out further and based on definitions developed and updated between 2010–2016, JCP defines clinical pathways as meeting four criteria: “(1) a structured multidisciplinary plan of care; (2) the translation of guidelines or evidence into an algorithm; (3) detailed steps within the pathway along a timeframe in a course of treatment/care plan; and (4) standardized care for a specific population.”
Oncology and outcomes
Clinical pathways cut their teeth in oncology and remain prevalent in a field marked by high treatment costs, expensive specialty pharmaceuticals, and a particular need for coordinated and integrated multidisciplinary care that spans every dimension of human need. Add to this the personal toll that a cancer diagnosis can bring.
There is no doubt that clinical pathways make a difference. “A clinical pathway will lead to better, more cost-effective care and outcomes,” says Wong. In addition to the efficacy, tolerability, and affordability cited earlier, he adds: “From a quality standpoint, it has been well documented that by decreasing the number of regimens, the staff becomes more familiar with the regimens being administered and they are able to support the patients better by being able to manage their experiences and toxicities.”
A new focus: Patient-centered
But given that clinical pathways are not ubiquitous, what remains? Patient-centeredness, says Wong. He notes that while prior objectives were weighted heavily to cost control, “we’re now looking at total patient care, SDOH, and triple aim; what’s coming to fruition is patient satisfaction. We [at the JCP] arrived at the conclusion that clinical pathways are used more today as a total tool.”
This perspective is reflected in the findings of the Journal of Clinical Pathway’s 2020 Oncology Benchmarking Survey. The primary reasons that oncology practices report utilizing pathways are to decrease treatment decision variability, improve care quality and outcomes, and streamline data collection. “Cost control, per se, came in lower compared to 2019,” says Wong, “possibly due to the shift from fee-for-service reimbursement to overall performance/outcomes-based reimbursement.”
Clinical Pathways University adds: “In a health care landscape undergoing a paradigm shift from a traditional fee-for-service to a value-based care model, clinical pathways represent the uniting of real-world clinical and financial data with medical practice as a means to drive precision and optimization of patient care.” It’s also important to note this might mean a clinical pathway is not utilized for select patients. The example Wong gives is an 80-year-old patient who may not tolerate chemotherapy well or require it if the cancer is controlled.
The role of integration and consolidation
As clinical pathways diverge in the wood, who will define this road less travelled? Payers will continue to lead but they are not alone. Wong cites CareFirst BlueCross BlueShield, Cigna, and Humana as innovative carriers, either independently or by working with third parties such as New Century Health. Today, providers are also using New Century, including Mercy Health, Cancer Care Specialists of Illinois, and Conviva Care Solutions. The latter is a Humana-practice management which prompts what role integration will have in clinical pathways’ brave new world.
With more stakeholders working with the same third parties, expect to see a reduction in the number of clinical pathways in favor of consolidation and streamlining. Wong notes that even programs created independently “appear to be a moving back towards using guidelines and compendia as the base, and then pairing down the treatment options based upon the needs and demands of the practice.” Collectively, these practices—along with clinical pathway-EHR integration—help solidify and streamline, reducing the variation that causes pathways to die on the vine.
CALLOUT: 61% of providers access pathways via the EMR, 25% via a separate system, and 8% using hard copy paper orders (Source: JCP 2020 Oncology Benchmark Survey)
This also occurs when providers align their pathways to their largest payer populations or attempt to identify common factors across business lines. Aligning to size and consistency reflects the pros and cons of healthcare reform—using existing volume and existing mechanisms as the only starting point while building the kind of stakeholder consensus that breaks down silos and ensures innovation is moving in the same direction across stakeholders.
Precision medicine and more specialties
The opportunity to apply clinical pathway beyond oncology to rheumatology, gastroenterology, cardiovascular, and other areas are making headlines. Notably, clinical pathways are also moving beyond not only oncology but pharmacology. MedPage Today and the American Society of Clinical Oncology (ASCO) are calling for pathways that “reduce their reliance on drug utilization” as more genomic, immunology, and cellular treatments emerge. The rise of precision and personalized medicine through these therapies could be the tide that lifts clinical pathways to full patient-centeredness.
“In a health care landscape undergoing a paradigm shift from a traditional fee-for-service to a value-based care model, clinical pathways represent the uniting of real-world clinical and financial data with medical practice as a means to drive precision and optimization of patient care.”
Winston Wong, PharmD, president, W-Squared Group.
Laura Beerman is a contributing writer for HealthLeaders.
Patient-centeredness is the logical next step in the era of precision and personalized medicine.
Payers and providers are leading the charge through integration dynamics.
These pathways are another critical step in the transition from volume to value.