Association of Patient, Physician, and Practice-Level Factors with Uptake of Payer-Led Oncology Clinical Pathways

Abstract

ImportancePayers use oncology clinical pathways programs to increase evidence-based drug prescribing and control drug spending. However, compliance with these programs has been low, which may decrease their efficacy, and factors associated with pathway compliance are unknown.ObjectiveTo determine extent of pathway compliance and identify factors associated with pathway compliance using characteristics of patients, practices, and the companies that develop cancer treatment pathways.Design, Setting, and ParticipantsThis cohort study comprised patients with claims and administrative data from a national insurer and a pathways health care professional between July 1, 2018, and October 31, 2021. Adult patients with metastatic breast, lung, colorectal, pancreatic, melanoma, kidney, bladder, gastric, and uterine cancer being treated in the first line were included. Six months of continuous insurance coverage prior to the date of treatment initiation was required for determination of baseline characteristics. Stepwise logistic regression was used to identify factors associated with pathway compliance.Main Outcomes and MeasuresUse of a pathway program–endorsed treatment regimen in the first-line setting for metastatic cancer.ResultsAmong 17 293 patients (mean [SD] age, 60.7 [11.2] years; 9183 [53.1%] women; mean [SD] Black patients per census block, 0.10 [0.20]), 11 071 patients (64.0%) were on-pathway, and 6222 (36.0%) were off-pathway. Factors associated with increased pathway compliance were higher health care utilization during the 6-month baseline period (measured in inpatient visits and emergency department visits) (5220 on-pathway inpatient visits [47.2%] vs 2797 off-pathway [45.0%]; emergency department visits, 3304 [27.1%] vs 1503 [24.2%]; adjusted odds ratio [aOR] for inpatient visits, 1.32; 95% CI, 1.22-1.43; P < .001), volume of patients with this insurance provider per physician (mean [SD] visits: on-pathway, 128.0 [258.3] vs off-pathway, 121.8 [161.4]; aOR, 1.12; 95% CI, 1.04-1.20; P = .002), and practice participation in the Oncology Care Model (on-pathway participation, 2601 [23.5%] vs 1305 [21.0%]; aOR, 1.13; 95% CI, 1.04-1.23; P = .004). Higher total medical cost during the 6-month baseline period were associated with decreased pathway compliance (mean [SD] costs: on-pathway, $55 990 [$69 706] vs $65 955 [$74 678]; aOR, 0.86; 95% CI, 0.83-0.88; P < .001). There was heterogeneity in odds of pathway compliance between different malignancies. Pathway compliance rates trended down from the reference year of 2018.Conclusions and RelevanceIn this cohort study, despite generous financial incentives, compliance with payer-led pathways remained at historically reported low rates. Factors such as increasing exposure to the program due to the number of patients impacted and participation in other value-based payment programs, such as the Oncology Care Model, were positively associated with compliance; factors such as the type of cancer and patient complexity may have played a role, but the directionality of potential effects was unclear.

Innovative Strategies and Technologies Streamline MIPS Participation

“…A cohort study comprising claims and administrative data from a national insurer and a pathways health care service found that despite generous financial incentives, compliance remained low at 64%. 70 Factors that influenced pathway compliance included patient factors, physicians' individual beliefs and routines, and peer effects. Factors that were positively associated with pathway compliance included increasing exposure to the program due to the number of patients impacted and participation in other value-based payment programs, such as the Oncology Care Model.…”

“…Factors that were positively associated with pathway compliance included increasing exposure to the program due to the number of patients impacted and participation in other value-based payment programs, such as the Oncology Care Model. 70 Cost-effectiveness analyses can be used by managed care decision-makers as a tool to help identify the value of a treatment. One costeffectiveness analysis by Yoo et al assessed the quality-adjusted life-years (QALYs) for 7 ICI/TKI drug combinations, including atezolizumab/ bevacizumab, avelumab/axitinib, pembrolizumab/ axitinib, nivolumab/ipilimumab, nivolumab/ cabozantinib, lenvatinib/pembrolizumab, and sunitinib.…”

Compliance with Clinical Pathways and Pilot Implementation Impact on Financial Outcome in Hospitals Using National Health Insurance: An Action Research

“…Implementing a care pathway has a double complexity: the care pathway itself and the linkages with the wider organization (Seys et al, 2019). Factors such as increased exposure to the program due to the number of affected patients and participation in other value-based payment programs were positively associated with compliance (Mullangi et al, 2023). Supportive resources, education/training, and better administration in general, hospitals should provide financial incentives to encourage physicians to adhere to CPs (Bai et al, 2019).…”