December 2023 Pathways Impact Study Part 2: Impact of Pathway Programs on Treatment Selection

 J Clin Pathways. 2024;10(2):3-5.

HMP Market Access Insights (MAI) sought to examine the actual impact of pathways on oncologists’ treatment decisions through primary research conducted in Q4 2023. Our study enrolled 130 oncologists into two arms: One arm included only oncologists whose medical group or integrated delivery network (IDN) was known to have implemented a pathway pro­gram (developed internally or licensed from a third-party ven­dor); a second arm included oncologists whose organizations did not offer their own pathways but were subject to payer path­ways. All participants stated they were aware of pathways and had at least occasionally consulted the pathway program.

A quantitative survey was conducted, followed by formal interviews and informal discussions with practicing oncolo­gists and pathway developers. These were supplemented with interviews and surveys conducted for HMP MAI’s provider and payer research programs in 2023. Finally, respondents completed a conjoint exercise designed to identify the most significant variables that impact physician drug choice from a preselected set of four attributes: pathway status, branded reg­imen (all options were National Comprehensive Cancer Net­work [NCCN] Level 1), compliance monitoring, and financial incentives tied to compliance.

This approach addressed challenges with earlier research showing that while oncologists make many “pathway-compli­ant” treatment selections, these decisions may reflect the path­way’s consistency with NCCN guidelines and do not indicate either awareness of or interest in the pathway’s recommenda­tion. We describe these decisions as evidence of “unconscious compliance.” For this research study, we included only on­cologists who were aware of pathways and explicitly referred to pathways.

Oncologists are subject to a wide variety of influences when selecting treatment for a patient. A product’s “on-pathway” or “off-pathway” status can be an important factor in the selection decision. Among oncologists subject to a pathway program sponsored by their organization, on- or off-pathway status is an important consideration and outweighs certain other at­tributes. Payer pathways are generally less impactful and may serve as “tiebreakers” where all other selection attributes are equivalent, and a favorable pathway position likely offers an efficient prior authorization and reimbursement experience.

Provider pathways’ higher impact arises from multiple fac­tors, including oncologists’ view of these pathways as being consistent with high-quality, high-value prescribing; fre­quent, but not universal, availability in the oncologists’ elec­tronic medical record (EMR); likelihood of monitoring; and frequent inclusion of compliance rates in the physicians’ an­nual bonus score.

Figure 1 shows the relative importance of “on-pathway” status in treatment selection for two different types of oncology clinical pathway programs: provider-sponsored pathways and payer-sponsored pathways. The y-axis represents the attribute value, which can be understood as the importance placed on a pathway’s status when making treatment decisions relative to the other attributes. The sum of the attribute values for each of the programs is 1.

A comparison of two leading, commercially available path­way programs and other internally implemented programs shows that pathways implemented and encouraged by an on­cologist’s organization are roughly equivalent in impact. This equivalence is despite variations in availability via EMRs. Payer programs were not tested separately and cannot be eval­uated similarly.

Figure 2 shows the relative importance of the three pro­gram options tested. Value Pathways and ClinicalPath are marketed to both oncology groups and IDNs by their devel­opers. The third category, “Internal,” includes pathway pro­grams developed independently by a single oncology group, by a committee drawn from a provider alliance or network (eg, OneOncology), or a less-prevalent pathway marketed by a developer (eg, Phillips/Dana Farber) and implemented by a single oncology group.

Pathways’ impact varies across tumors for both payer- and pro­vider-implemented payer pathways, with higher variation seen in provider programs. This is consistent with the non-conjoint section of our survey instrument, which showed that oncolo­gists refer to pathways at different rates for the nine tumors included in that section.

Figure 3 compares the maximum and minimum impacts across the four tumors included in the conjoint exercise. Note that variation was wider among provider pathways than among payer pathways and that even the minimum relative importance score for providers exceeded the payer pathways’ maximum relative importance.

Interviews with participating oncologists suggested that tumors with multiple treatment options viewed as roughly clinically equivalent (eg, metastatic, hormone receptor–posi­tive breast cancer) saw the highest impact while tumors in which a particular treatment option was seen as clinically su­perior generally had lower pathway impact.

A future column will share a final set of insights looking at the quantitative impacts of payer and provider pathways in the four tumors included in the conjoint exercise, including differ­ences among brands.

Author: Lee Blansett, MBA

Affiliation: Executive Vice President, HMP Market Access Insights, San Mateo, CA.

Disclosures: The author reported no relevant financial or other conflicts of interest.