How Payers are Getting Pathways all wrong in Medical Oncology

How Payers are Getting Pathways all wrong in Medical Oncology

Payers, Pathways & Unicorns

How Payers are Getting Pathways all wrong in Medical Oncology

Dr. Jeff Patton, Wes Chapman, Aaron Lyss

September 21, 2014


Unicorns: everyone knows what they look like, but nobody has ever seen one

We are in the middle of building a comprehensive medical home, for the benefit of all of our patients. At its core, the medical home offers a very simple premise – focus the team of caregivers on the patient’s needs, and manage those needs according to established best practice pathways. The medical home requires a major effort in clinical care definition and conformance, and in the future will need to comply with the still fuzzy requirements of value based care; ultimately requiring diving off the Ivory Tower of clinical practice, and into real-world maelstrom of disparate requirement of individual payers.

We hosted a visit from the technical team of prominent national payer last week, investigating the use of clinical pathway software for medical oncology. The meeting went along fairly well, until the conversation turned to the actual specifications of what they were looking for, namely “a system that will allow us to support NCCN based pathways for our patients, and provide accurate and timely attribution and compliance metrics”. Unfortunately, for the vast majority of oncology practices in the US, the EMR does not provide access to best practice clinical pathways, and the pathway systems in use typically are not capable of fulfilling the computerized physician order entry (CPOE) functions always associated with sophisticated EMRs.

Our payer visitors were looking for a unicorn – everybody knows what they should look like, and nobody has ever seen one. While the normal unicorn is a fanciful combination of a narwhale’s horn with a horse; our payer friend’s unicorn was the combination of a stable, validated CPOE system with a clinically valid oncology pathways system – which requires constant review and updates by dedicated teams of clinicians doing extensive literature reviews. Like the narwhale and the horse, pathway and EMRs are vastly different creatures, thriving in very different environments. Their combination would require a hybridization task that is difficult in the extreme.


Hybridization with a horse represents a mighty task

This would not be a problem, except that payers have become infatuated with the concept of getting compliance data from their “proprietary” pathway systems. All of these pathway systems must meet the “NCCN compliant” standard, and so actually differ very little in the recommended drug regimens that they contain. By and large, none of them are capable of delivering either auditable attribution or compliance metrics. Without direct and continuous interaction with the underlying EMR, the compliance and attribution data cannot be relied on for either accuracy or completeness – the reported results may be as fanciful as a unicorn sighting. You just don’t know.

Several of the practices with whom we correspond frequently are burdened with up to six of these separate pathway systems. This requires an unconscionable administrative burden, bouncing between six unique electronic systems – all required to execute a task that they are incapable of accomplishing – providing reliable attribution and compliance data. This multiplicity of pathways introduces a huge amount of variability into clinical delivery systems which might otherwise be stable and reproducible. It is nuts.

“What we need to do is learn to work in the system, by which I mean that everybody, every team, every platform, every division, every component is there not for individual competitive profit or recognition, but for contribution to the system as a whole on a win-win basis”

“We must understand variation.”

If you can’t describe what you are doing as a process, you don’t know what you’re doing.

Edwards Deming


Eliminating unwanted (special cause) process variability is the fundamental driver of process quality – everywhere and always. Our experience is that physicians in our practice follow identified regimens around 50-60% of the time prior to the implementation of a pathways system. Like most large practices we currently standardize practice to reduce drug waste and ensure uniform practice between our physicians and nursing staff. We are putting a new pathways system in place to help improve this to an 80% level. If all of our payers were to mandate separate pathway systems, and we complied, we would probably fall to less than 50% compliance with our existing pathways – increasing costs and decreasing quality.  Payer mandated pathway proliferation simply increases variation – degrading quality to the patient.

When payers mandate multiple pathway systems, it dramatically increases the complexity of care. This complicates how orders are placed into the EMR, increasing the potential for medication errors, provides substantial administrative cost and burden, and provides no benefit at all for the intended beneficiary – the patient. We understand that the real motivation from payers is timely attribution of beneficiaries to clinical pathways, and subsequent compliance reporting. Unfortunately, when you move to a multiple system environment, it is virtually impossible to provide either accurate or timely compliance data.

There is a simple solution to this madness – payers have every right to know that their beneficiaries are receiving best practice based care determined by NCCN compliant pathways, and that attribution to and compliance with those pathways meets minimum quality standards – say 90% and 80% respectively. Practices using any high quality pathways system can provide care plans to payers at the time of attribution, which can provide the basis for attribution and compliance reports directly from the practice’s EMR. This is simple, direct and can be accomplished without the hassle and expense of multiple pathway systems. It facilitates uniform practice, and is based on data from the EMR – the only system in the mix designed to provide reliable data. And it does not require belief in unicorns. But it does require really understanding how medical oncology data and practice management work, and how to use them to reduce cost and improve care.

In our next blog we’ll outline how existing systems can be made to conform to existing and prospective payer requirements. It will require substantial changes to the existing prior authorization systems (including a dramatic upgrade in clinical capabilities).

Wes Chapman
Written by Wes Chapman

1 Comment responses

  1. Avatar
    March 18, 2015

    It seems that there is a common theme emerging in healthcare – transparency.