U.S. Payer and Prescriber Perspectives on Clinical Pathways, Bundled Payments, and Accountable Care Organizations

As the U.S. healthcare market faces an avalanche of expensive specialty drugs in the pipeline, managed care organizations (MCOs) are increasingly evaluating reimbursement through the lens of value-based, cost-efficient care. Clinical pathways have become more prevalent in cancer treatment as stakeholders seek to standardize best care and control costs. MCOs also seek to control costs and quality through bundled payments, which pay providers a single payment for an episode of care, and accountable care organizations (ACOs), which hold providers responsible for the total cost of care of a patient population. In this U.S. Physician & Payer Forum report, we examine the impact of these payment schemes on reimbursement and prescribing of breast cancer drugs—including chemotherapy regimens, hormone treatments, and targeted therapies—for the HER2+, HR+/HER2-, and triple-negative patient populations. We also discuss clinical pathways’ and bundled payments’ current and future handling of supportive care drugs to prevent and/or treat neutropenia. Forty-one U.S. MCO directors and 102 oncologists/medical oncologists were surveyed for this report.

Questions Answered in This Report:

  • Clinical pathway programs (CPPs) are designed to establish optimal treatment protocols based on best clinical evidence and thus promote cost-effective therapies. However, MCO-led CPPs place more emphasis on cost metrics than current oncologist-led CPPs do. What do MCOs plan to do if they cannot obtain buy-in from physicians on following their clinical pathways? What drugs are permitted in the pathways developed by MCOs? What drugs are permitted in the pathways of oncology groups, and do they differ markedly from MCO pathways? Which drugs would oncologists prefer if they could treat patients without the impact of clinical pathways? Do oncologists wait to prescribe emerging therapies that are not yet added to MCO pathways?

  • Both oncologists and MCO directors expect the use of bundled payments to increase. What do MCO directors report about the number of oncologists they expect to compensate via bundled payments in two years? How do bundled payment programs treat supportive care drugs? What are the components of MCOs’ bundled payment programs? How do MCO directors view the potential of bundled payments in terms of improving outcomes and reducing costs?

  • Although many ACOs are not focused specifically on oncology, cancer is increasingly examined in the context of the accountable care movement, and breast cancer leads the oncology indications considered ready for an ACO focus. Why do interviewed experts in ACOs view breast cancer as a productive focus of the ACO? What are some of the ACO metrics that focus on breast cancer drugs? What do ACO experts say about the use of branded versus generic chemotherapies in breast cancer? What do ACO experts say about to the use of aggressive chemotherapies at the later stages of treatment?

Scope:

Decision Resources Group’s U.S. Physician & Payer Forum report “Managed Care Strategies in Breast Cancer: U.S. Payer and Prescriber Perspectives on Clinical Pathways, Bundled Payments, and Accountable Care Organizations” contains insights from a survey of 102 oncologists/ medical oncologists and 41 MCO PDs/MDs regarding the impact of clinical pathways, bundled payments, and ACOs on the prescribing and reimbursement of breast cancer drugs for the following patient populations: HER2+, HR+/HER2-, and triple negative.

Markets covered: United States.

Primary research: Online survey of 102 oncologists and 41 MCO PDs and MDs and qualitative interviews with MCO and provider officials involved in ACOs.

Author(s): Paula Wade

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