Making Medical Oncology Pathways Work for Patients, Providers and Payers
Using the PSO Structure to Benefit all Parties
Finding the Unicorn – Making Order from Chaos
Wes Chapman & Aaron Lyss
December 6, 2014
In our September blog regarding medical oncology pathways, we examined what payers are trying to get out of the current system, and why they have been disappointed. While they look for best practice conformance and cost control from disparate and proprietary clinical pathway systems, they are instead finding provider resistance and growing confusion. The variation in process that their proprietary pathways impose on practices result in decreased quality and increased cost, and have done little to reduce payer dependence on clumsy, expensive and ineffective prior authorization methods.
In this follow up blog, we address,” 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)”; points we raised at the end of our last blog on the subject.
Making Order from Chaos
A Problem Solved in Three Parts
First, the easiest problem to address is technical: How to convert pathways selected in any one of 6-7 commercially available pathway systems into a single equivalent pathway system selected by an individual payer. Remember that all of the pathway systems are “NCCN compliant”, and 85%-90% of all pathways used by large medical oncology practices are clinically equivalent – differing in minor ways which typically do not change clinical utility, toxicity or cost. From a technical basis, this is pretty trivial, and the diagram below shows a very straightforward solution to this part of the problem.
Database Recognizes and Interprets disparate nomenclature
The second part of the problem however, is clinical, and a lot more problematic to fix: who determines when differences stop being trivial, and start being meaningful. This is a bigger problem than you might first imagine, because the individual pathways can differ in small but important ways between practices; as an example, dosages may differ by small amounts, and supportive drugs may be quite different, or entirely unspecified by some practices. Someone, or some group, must be trusted to provide the adjudication fairly, and according to the criteria agreed to by the individual practices and payers. Furthermore, pathways are continuously updated – typically quarterly – to keep up with current literature about best practices.
There are currently parties capable of delivering the required clinical oversight needed to make the database work: 1) The design and/or validation of NCCN compliant pathways for payer selected systems, and 2) The validation of individual practice pathways as compliant with specific payer requirements. This is a fair amount of work, and requires a large compliment of unbiased and well informed clinical experts. It is pretty clear that a vendor like Via Oncology has a committee based system that meets most of the requirements associated with this problem, and may be able to gear up to offer the clinical validation needed.
Database facilitates interoperability, pathway validation, payer notification & approval
The third part of the problem is how to take advantage of the data that is generated by the system. A Patient Safety Organization (PSO) offers a number of very important advantages that would be beneficial in this structure. PSOs are designed to gather data in confidence and under pre-determined protocol, exclusively for the benefit of patient care and safety. The structure was created by the Patient Safety Act of 2005, is administered by AHRQ and attaches privilege and confidentiality to “patient safety work product” for data in the PSO.
From a practical perspective, this allows the use of pooled clinical data from multiple provider groups to be analyzed and interpreted for the benefit of patient care. PSOs are normally chartered with the involvement of one or more medical societies, to ensure effective collaboration. What makes the use of a PSO so compelling in this structure, is that multiple pathways are being mapped to common definitions, and the collection of safety and outcome data associated with the standard pathways would provide compelling outcome data. Because the physicians providing care are also interpreting the data, relevant cohorts can be developed – reflecting the full range of selection criteria.
While it is not permitted to sell data out of the PSO, participating members can decide to pool their data for commercial use outside of the PSO – providing truly meaningful data for pharmaceutical and device companies to evaluate and improve their products.
What is most important from our perspective is that the patients interests come first, and patients benefit before anyone else. We feel that it is absolutely critical that the focus of the system be patient care – commercial interests must take a back seat. Second, we recognize the primacy of the patient /physician relationship, and want to do everything possible to empower providers with relevant data to improve patient care and safety. Finally, we recognize, however, that strong and viable research is greatly aided by the use of good data, and that payers need to be able to control costs and escape from the overly costly and intrusive prior authorization systems available today.
Clinical pathways offer the ability to dramatically improve medical oncology care as well as reduce variability in care delivery. Like all innovations, clinical pathway systems in oncology require new application methods to achieve their full value – and we think that this system goes a long way to achieving that potential.