1. ANCO Members Need a Strategy. Managed care payers want oncology solutions that reduce variation and cost. Oncology physicians want stable decision-making in the best interest of their patients, and payer contracts that allow cancer centers and community offices to continue to provide care. But, without a strategy to bring to the table, physicians become vulnerable and ineffective in effecting change or improvements.

2. Taking Control versus Losing Control. Payers need to effect changes in oncology management and costs, in response to demands from their customers—the employers. Payers want to work with physicians, but will take action with others who want to implement their own oncology management programs if physicians are not pro-active. Being pro-active lets you shape solutions instead of being dictated to by a non-oncology vendor.

3. It is About Medical Decision-Making, Not the Drugs. Vendors are bringing models to payers that focus on short-term savings in drug control and management. More than 75% of the total payer spend in oncology is not for services or drugs delivered in the physician office (e.g., hospitalization, end-of-life care, diagnostics, imaging, etc). Medical decision-making belongs with the physician, and so physicians should craft solutions that involve medical decision-making, but with an eye toward total cost management for the benefit of the patient and the payer as well. Done correctly, clinical pathways decrease costs in the physician’s office, and even more across the entire care continuum.

4. Compelling Savings Opportunities Lie in Physician Decisions That Go Beyond Drugs and Office Services. ANCO members engaged in active medical decision-making and payer strategies can find significant savings for payer partners without direct impact on the practice (in diagnostics, reduction of hospitalization, and end-of-life care). Individual practices alone cannot generate noticeable savings, but clinical choices done collectively through payer provider partnerships, can be compellingly effective.

5. Front-End Compliance Models Best Support Physician Medical-Decision Making in Physician Payer Partnership Models. Consider the following characteristics present in the Via Oncology and Innovent Oncology models:

• Clinical Source and Maintenance: A viable clinical pathway program must be firmly grounded in evidence-based clinical information and undergo rigorous clinical review by an experienced body of physicians.

• Pathway Definition: A true clinical pathway is increasingly clarified as the identification of one preferred treatment for a given state and stage of disease, which has been selected via a rigorous clinical review of the appropriate clinical guideline alternatives, and selected based first upon clinical efficacy, then toxicity profile, and, lastly, assuming comparability across the first two criteria, cost of treatment. Basically, guidelines can be considered as a multi-lane highway, and pathways are one lane.

A clinical pathway program will always allow physician flexibility to treat with an off-pathway alternative, since there is no one preferred treatment that will be universally applicable to all cancer patients 100% of the time.

The scope of a pathway should include not only chemotherapy infusibles and injectables, but also orals, biotherapies, supportive care drugs, prognostic testing, and ideally also radiation oncology. Clinical trials should always be considered an “on pathway” choice.

• Point of Clinical Decision-making: Physician medical decision-making is complex for cancer patients, and involves multiple branches and considerations within a given disease to identify the state and stage of the disease, as well as to think through the many complications of the individual patient’s health and physical status. These front-end models protect and support the complexity of physician decision-making.

• Tracking and Monitoring: A true clinical pathway program will allow for physicians to select treatment options that are off pathway where appropriate, but track the reasons and causes for such variation as part of the clinical monitoring feedback loop. Reporting and analysis should be available to the physician on a patient and population basis.

• Documented Ease of Physician Use: A point of clinical decision-making tool is only as good as the number of times it is used by physicians in active clinical practice. Most physicians who embrace the selection of pathways decide to apply the pathway process to all their patients, making ease of use on one pathway platform across all patients essential.

ANCO is introducing its members to two credible front-end compliance models. In future discussions with payers, ANCO will seek solutions that utilize reporting which could be driven by either system, leaving its members to choose credible models that will compliment their own clinical practice and operations choices.

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ANCO's Payer Provider Partnership Strategy