ASCO Provides Recommendations to Ensure Clinical Pathways Deliver High-Value Care

Clinical pathways—developed internally by clinics or recommended by healthcare payers—are rapidly being adopted into clinical practice. Clinical pathways are a means to increase clinical transparency, stratify available options, and use the most “valuable” treatment plan. However, implementing payer-determined clinical pathways has raised numerous concerns among physicians, and the American Society of Clinical Oncology (ASCO) has released a policy statement on clinical pathways in oncology that address some of these concerns.

Developed by a Task Force on Clinical Pathways, established by ASCO’s Board of Directors, the recommendations aim to promote evidence-based, high-value care that respects the demands of patients, payers, and providers.

“It's time to seriously examine the way clinical pathways are designed and implemented to ensure they consistently enhance, rather than diminish, patient care,” said ASCO President Julie M. Vose, MD, MBA, FASCO. Said in an associated press release. “In too many cases, clinical pathways are undermining physicians' ability to optimally care for their patients with cancer and limiting patient choice.”

Payers have been offering incentives to providers for using oncology pathways, the authors write, which include increased reimbursement and case management fees for adherence, shared savings, and risk sharing. For practices that are a part of an accountable care organization, clinical pathways can help integrate care delivery if the practices do not share a common electronic health record. As a major player in payment reform, adoption of pathway programs has also been shown to save costs.

There are limitations to the use of clinical pathways, however, and ASCO’s policy statement points to a number of issues that may pose significant barriers to providing high-quality, evidence-based cancer care. ASCO is calling for clinical pathways to better accommodate the diverse circumstances and characteristics of patients with cancer. Pathways should be expanded to address the full spectrum of cancer care and updated regularly to reflect the latest in evidence-based clinical practice. ASCO is also calling for a reduction in the administrative burden that pathways place on physicians, so that more time can be devoted to serving patients.

Following are the concerns raised by the Task Force about the way in which clinical pathway programs are currently developed and implemented in oncology practice:

1. Lack of consistency by insurers and other pathways creators has resulted in wide variations in quality and utility.
2. Oncology pathways are often too rigid and many place too much emphasis on cost control.
3. Oncology pathways are often focused only on the selection of anticancer agents and do not include other critical aspects of cancer care, including diagnostic evaluation, laboratory testing, and palliative care services, which are central to quality patient care.
4. The oncology pathway development process today, in many cases, is not transparent to patients and providers.
5. There is no system in place to guarantee the integrity of pathways coming to market, or to ensure they are implemented in a manner that supports high-quality patient care.

Robin T. Zon, MD, FACP, FASCO, chair of the Task Force, pointed to the cookie-cutter approach of some of the clinical pathways, highlighting the contradiction it creates with the current environment of personalized medicine. “When doctors diverge from a clinical pathway, even for well-justified reasons, payers are likely to either deny coverage or require prior authorization, which can delay treatment and threaten patients' health,” Zon said in an associated press release by ASCO.

Another concern is the growing administrative burden on physicians, who already report spending as much as one-sixth of their day on paperwork,³ limiting time with their patients. At ASCO’s annual meeting last year, Zon spoke to the audience on the impact of these growing physician administrative burdens on healthcare.

The ASCO policy statement includes the following key recommendations to improve the development and use of clinical pathways in oncology:

1. Pursue a collaborative, national approach to reduce the unsustainable administrative burdens associated with the unmanaged proliferation of oncology pathways.
2. Adopt a process for development of oncology pathways that is consistent and transparent to all stakeholders.
3. Ensure that pathways address the full spectrum of cancer care, from diagnostic evaluation through medical, surgical and radiation treatments, and include imaging, laboratory testing, survivorship and end-of-life care.
4. Update pathways continuously to reflect new scientific knowledge, as well as insights gained from clinical experience and patient outcomes, to promote the best possible evidence-based care.
5. Recognize patient variability and autonomy and allow for physicians to easily diverge from pathways when evidence and patient needs dictate.
6. Implement oncology pathways in ways that promote administrative efficiencies for both oncology providers and payers.
7. Promote education, research and access to clinical trials in oncology clinical pathways.
8. Develop robust criteria to support certification of oncology pathway programs; pathway programs should be required to qualify based on these criteria, and payers should accept all oncology pathway programs that achieve certification through such a process.
9. Support research to understand the impact of pathways on care and outcomes.