Payer-Led Clinical Pathways in Oncology: A Case Study in Unintended Consequences

J Clin Pathways. 2026;12(3):e001 doi:10.25270/jcp.2026.05.001

When oncology clinical pathways first emerged in the mid-2000s, the rationale was clear and easy to understand: they were designed to address pressing challenges in cancer care. At the time in the US, cancer care was expensive, highly variable, and not delivering outcomes commensurate with our investment. The US spends approximately $15 000 per capita on health care annually, almost double what peer nations spend,¹ yet cancer survival rates and other outcomes are not consistently better. Within our own system, the variability is striking; where a patient lives, which oncologist they see, and which institution treats them all drive care decisions in ways that are unrelated to tumor biology or clinical evidence. Cancer death rates vary meaningfully across the country,² and there is a nearly threefold difference in end-of-life treatment intensity between the 5th and 95th percentiles of practicing oncologists.³ Meanwhile, global anticancer drug spending reached $99 billion in 2023 and is projected to increase to $180 billion by 2028, a pace of growth that is difficult to comprehend, let alone manage.⁴

Pathways were developed as a direct response to these realities. High-quality, evidence-based treatment protocols would standardize care around the most effective options, reduce low-value prescribing, and simplify the prior authorization process for both providers and payers. The University of Pittsburgh Medical Center developed Via Pathways in 2004 to bring consistency across its 40-site network. US Oncology followed in 2005, and over the next 2 decades, a proliferation of provider-oriented and payer-oriented pathways programs came to market. Today, roughly 75% of integrated delivery systems have adopted some form of pathways solution.⁵ National payers and many regional plans have followed, often pairing pathway compliance with pay-for-performance incentives designed to reward on-pathway prescribing. So why, after 20 years and widespread adoption, are we still talking about unwarranted variation in cancer care? And why are oncologists increasingly frustrated rather than grateful?

Part of the answer lies in what the evidence actually shows. A 2017 study of the Dana-Farber Cancer Institute experience demonstrated small but measurable clinical and financial benefits from pathway adherence. The authors showed a reduction in 12-month total cost of care for patients with metastatic non-small cell lung cancer (NSCLC) of approximately $15 000 from the pre- to post-pathways setting, without change in survival.⁶ The result is meaningful but modest when you consider that the cost of a single dose of pembrolizumab falls in the same range. Furthermore, these findings were generated by an institution with deep clinical and operational infrastructure and the kind of subspecialty depth that is difficult to replicate outside a large academic medical center. The broader literature is less encouraging, particularly for payer-led programs. A large cohort study examining the Elevance pathway program, which at the time offered practices $350 per member per month for compliance, found an on-pathway rate of 64%, which declined over time.⁷ The authors noted that payer-led pathways are often not integrated into the electronic ordering system, meaning oncologists may not know which treatment is on-pathway at the moment of clinical decision-making. That is a structural problem that will not be easily fixed by financial incentives alone.

The physician frustration is of critical importance. Oncology practices are frequently subject to multiple pathways requirements from different payers. Older reports suggest that some practices navigate up to 8 different pathways systems simultaneously,⁸ and this number is likely increasing. These programs differ in their drug and regimen preferences, the data elements they require, their handling of off-label choices, and how current they are relative to the approved drug landscape and evolving guidelines. Unless a pathways program is exceptionally well-maintained, it tends to lag behind the evidence. In fast-evolving disease areas like NSCLC, where new approvals and biomarker-driven treatment decisions have proliferated rapidly, the lag matters clinically. In 2025, there were 54 new US Food and Drug Administration (FDA) approvals in oncology,⁹ with 2026 trending similarly as the pipeline continues to grow. Innovative therapies are entering the market faster than payer management frameworks can adapt. The science is also moving toward more complex regimens. Last year, 51% of oncology indications approved by the FDA were for combination therapy regimens, and 63% of FDA-approved oncology cross-benefit regimens included precision medicine requiring a specific biomarker to select the best option.¹⁰ It is not surprising that 80% of oncologists report feeling overwhelmed by the volume of new information.¹¹ The promise of reducing administrative burden has, in many cases, produced the opposite effect.

There are also fundamental differences between provider-oriented and payer-oriented pathways that are important to address. Provider pathways are developed by committees of practicing oncologists, often with subspecialty depth and quarterly or continuous update cycles. They are usually embedded in the electronic health records and function as clinical decision support at the point of care. While payer pathways often incorporate input from practicing oncologists as well, they typically engage fewer subspecialists and are aligned to coverage policy. Payer pathways tend to be enforced through the prior authorization process and are disconnected from the treatment ordering workflow, which means that clinicians are less likely to engage with them than administrative staff. In many cases, we have observed that payer pathways omit clinically relevant patient nuances in an effort to simplify the offering. This can be a particularly problematic and even risky gap given that payer pathways are mandatory rather than advisory.

Of course, physician-developed pathways also require time, governance, and constant maintenance. This is challenging in an era in which practicing oncologists are seeing more patients while simultaneously spending more time on administrative work. For many community groups, that reality makes it difficult to develop and sustain a comprehensive internal pathways program across all tumor types. Practices may opt to purchase a vendor solution, but prices are nontrivial because of the work required to maintain these systems; this also presents a challenge as practices struggle with a wide range of financial pressures.

At OncoHealth, our perspective on pathways has evolved based on what we see among more than 20 diverse payers nationwide. Pathways were designed to address an important set of problems that continue to adversely impact the US cancer care ecosystem, but the proliferation of pathway programs in the market has, paradoxically, made the goal of reducing variation harder to achieve. When multiple payers deploy their own pathways with unique vendor and drug preferences, and frequently without regard to the presence of a provider-facing pathway solution, the overall effect is even more fragmentation. The administrative burden of all this pathway work falls disproportionately on community oncology practices that lack the infrastructure or financial robustness to manage multiple non-overlapping requirements.

Our recommendation to health plan clients is to consider an alternative approach: anchor clinical review standards to National Comprehensive Cancer Network (NCCN) Guidelines and high-quality published evidence rather than proprietary pathway tools. Admittedly, NCCN Guidelines are a comprehensive clinical reference that may be challenging for a busy oncologist to navigate during clinic time. On the plus side, they are updated continuously, broadly accepted by oncologists and other industry stakeholders, developed by committees of oncologists with disease-specific expertise, and do not require practices to manage unique workflows. In a world of new cancer drugs and indications, combination regimens, and biomarker-driven prescribing, continuously updated, oncologist-led standards are more scalable than proprietary content or tools. Payers can layer in prior authorization with drug-specific, evidence-based policy guidance for clinically complex or particularly high-cost decisions and can contemplate gold-carding or other prior authorization relief programs for practices that consistently adhere to evidence-based standards. Value-based care programs that are thoughtfully designed to encourage high-value prescribing can also be employed. For plans that work with oncology groups that have internal pathways programs, there is an opportunity to incorporate pathway adherence data into the authorization workflow rather than duplicating it through a separate payer program.

The underlying goal, better outcomes at lower cost, is one that payers and oncologists share, even if it does not always feel that way in the day-to-day dynamic of prior authorization. The tools we use to pursue that goal should be evaluated honestly against the evidence, and where the evidence is thin or the administrative costs are high, there is an obligation to consider whether there is a better path. For oncology pathways, honest accounting points toward a more targeted, evidence-anchored approach. The good news is that the infrastructure to support it—continuously updated, clinician-led guidelines within existing utilization management frameworks—is already in place.

• Payer-led oncology clinical pathways were developed to reduce treatment variation, improve adherence to evidence-based care, and control costs, but evidence supporting their effectiveness remains limited.
• Multiple payer-specific pathway programs can increase administrative burden, create workflow inefficiencies, and struggle to keep pace with rapidly evolving oncology treatments, biomarkers, and FDA approvals. 
• Replacing proprietary pathway requirements with clinical review anchored to continuously updated NCCN Guidelines and high-quality evidence, supported by targeted prior authorization and incentives for high-value care, is recommended.

Authors: Andrew D. Norden, MD, MBA, MPH¹

Affiliations: ¹OncoHealth

Address correspondence to: 

Andrew D. Norden, MD, MBA, MPH
Chief Medical Officer
OncoHealth
7000 Central Pkwy, Suite 1750
Atlanta GA 30328
anorden@oncohealth.us
Phone: 888-916-2616

Disclosures: A.D.N. is employed by and holds equity in Oncology Analytics, Inc doing business as OncoHealth.