No one likes the idea of physicians practicing cookbook medicine.
It seems the very opposite of personalized medicine, which medical technologists herald as medicine's newest new thing.
Yet providers and insurers increasingly are asking physicians to use preordained treatment plans called clinical pathways. It's especially true in cancer care.
The medical evidence generated by these early adopters, while limited, shows it hasn't harmed patients even as it has reduced the overall cost of care. More significantly, there is a strong likelihood that many patients will receive better care when scientifically validated pathways become more prevalent, because, in many areas of medicine, physician practice frequently diverges from evidence-based guidelines. Or, doctors deploy heroic interventions that add little to a dying patient's remaining life, even as they sharply reduce its quality.
In cancer care, about 1 in 3 patients do not receive treatments that conform to best practices drawn from the medical literature. The problem, of course, is how to educate patients and physicians about that reality.
Two powerful forces contribute to this misallocation of resources. First, providers have strong financial incentives for delivering non-evidence-based care. Cancer docs, for instance, get a markup on the pricey drugs they administer in their offices. Hospitals get a hefty facility fee every time they administer another round of chemotherapy in their clinics.
Second, as Dr. Atul Gawande's new book, Being Mortal, documents, physicians and provider organizations are ill-trained and financially unrewarded for discussing the difficult trade-offs involved in end-of-life care. Patients and their families are psychologically ill-prepared and culturally averse to having those discussions.
Yet no field has progressed farther down the path of adopting clinical pathways in recent years than oncology. The need is overwhelming.
The medical literature endorses multiple approaches to treating the hundreds of forms of the disease that strike 1.6 million Americans a year, progress through various stages, and, for more than a half million people a year, end in death. At the same time, the latest cancer treatments coming from the pharmaceutical industry's labs have forced everybody involved in patient care to weigh the limited benefits of new treatments against their skyrocketing cost.
A number of organizations are rising to the challenge on the provider and insurer sides. The American Society of Clinical Oncology, which speaks for the nation's oncologists, last spring endorsed a list of guidelines and best practices to encourage the use of clinical pathways in cancer care, including requiring input from oncologists, providing leeway for deviation and allowing physician practices to use a single set of pathways for all insurers.
Last July, WellPoint rolled out its oncology clinical pathways reimbursement policies in a number of states, including Georgia, Kentucky and Ohio. Its plans offered oncologists a $350 management fee each month if they adhered to clinical pathways that were drawn from a guidelines review conducted by leading academic and community oncologists.
Not following the pathway resulted in a loss of the management fee. It did not prevent reimbursement for the prescribed care.
Yet you wouldn't have known that fact after reading the op-ed article in the New York Times last week attacking clinical pathways. Drs. Pamela Hartzband and Jerome Groopman of Harvard Medical School bemoaned the “financial forces largely hidden from the public (insurers, hospital networks and regulatory groups)” that “are beginning to corrupt care and undermine the bond of trust between doctors and patients.” They feared the “moral licensing” that will come from incentivizing physicians to force or withhold treatments based on what's good for the overall population, not the individual patient.
Alas, nary a word about the long-standing financial licensing that incentivizes inappropriate care.
To prevent a popular backlash from undermining use of this promising tool, providers and insurers must become much more open about how they construct clinical pathways. Unfortunately, WellPoint has refused to release the names of the oncologists who sat on its committee or the papers and guidelines that informed its pathways, claiming that was proprietary information. Being opaque is a serious mistake.
Providers and insurers have a difficult enough challenge in educating the public about why, in most circumstances, population-health medicine is also best for most individuals. Being transparent about the clinical pathway development process will aid that task immeasurably.
