Clinical pathways under Medicare?

Pharmaceutical CommercePharmaceutical Commerce - May/June 2014

According to the American Cancer Society, Medicare spent $34.4 billion for cancer care in 2011. Between 2010 and 2030, 78 million baby boomers will turn 65 at an estimated rate of 10,000 per day (according to the 2013 Genentech Oncology Trend Report).

“Thus far, the largest payer in oncology—the Centers for Medicare and Medicaid Services (CMS)—has had a limited involvement in pathways programs in Medicare or Medicaid,” says Deni Deasy Boekell, a senior director at Kantar Health. But this may be about to change, as advocates are working with CMS to demonstrate the potential cost savings.

While Medicare is already the largest insurer in oncology, its lack of any clinical pathways requirements is cited by some as an enormous loss of opportunity in the drive for continuous improvement and reduction of cost in cancer care. Today, preliminary efforts are underway to engage the Centers for Medicare and Medicaid when it comes to clinical pathways. This could have big implications on pathways adoption, since private payers often follow Medicare’s lead when it comes to reimbursement and coverage decisions.

CMS is currently reviewing one or more value-based reimbursement structures for oncology, which will focus at least in part around the impact of clinical pathways on Medicare expenditures in oncology practices and hospitals. McKesson Specialty Health, The US Oncology Network and the National Comprehensive Cancer Network, among others, have submitted a pilot project proposal to CMS as part of this effort. These pilots are expected to come to fruition later this year and if successful, Medicare may expand them more broadly within two to three years.

Similarly, Cardinal Health has a CMMI Innovations grant under review and hopes to be funded for its first CMS-sponsored pathway later this year. “Among our commercial pathways clients, many have already extended the programming to their managed Medicare members,” says Feinberg of Cardinal Health.

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