Payer current and future utilization of pathways: A research study.

Abstract

273 Background: Clinical pathways are a growing payer management technique for controlling costs and standardizing care. Their use in other therapeutic areas has helped payers control costs and standardize care; however, use of pathways in oncology has not been assessed. Methods: There were a total of 49 respondents, including 19 Medical Directors and 30 Pharmacy Directors, covering 100 million lives in the US across all channels (Medicare, Commercial, and Medicaid). Approximately 39% of respondents were from small plans (covering less than 750,000 lives), 28% were from medium-sized plans (covering 750,000 – 2.5 million lives), and 33% of respondents represented large plans (covering more than 2.5 million lives). About 33% of respondents were from national plans, while 67% were from regional plans. Results: Only 39% of payers have actually implemented pathway programs in oncology. Of the payers surveyed that did not already have a clinical pathway, 59% said they are not currently implementing pathways. However, among those who are using pathways, a disproportionate share is commercial plans (42%) and Medicaid (40%), not Medicare (25%). Only 25% of Medicare-focused plans anticipate implementing clinical pathways in the future, while more than 40% of commercially-focused plans intend to do so. About half of plans (53%) anticipate that pathways also will be integrated into provider ratings, and a minority, (42%), see a role for pathways in product formulary placement or tier status. When payers have implemented pathways, the tumor types with the highest costs have been initial targets, with breast (84%), lung (63%), colorectal (63%), and prostate (37%) with the highest penetration of pathway implementation. Conclusions: Payers view clinical pathways as an important tool for reducing drug costs, especially with respect to tumor types that carry high treatment costs. Near-term strategies like step edits and coverage via the pharmacy vs. medical benefit will continue to play a significant role in oncology reimbursement decisions, but product companies need to understand how existing clinical pathway programs will impact provider access to products to more accurately forecast their future impact as the concept gains national traction.