It’s no surprise to anyone that the cost of oncology care is hard to keep up with. According to the Summer 2019 Magellan RX Management Report, oncology agents account for 34% of the total medical pharmacy spend for commercial, 46% for Medicare, and 35% for Medicaid.
Medical benefit oncology drugs are a sore spot for payers as these drugs are difficult to manage with traditional utilization management tools such as step edits and quantity limits. As a matter of fact, many payers will admit that using these utilization management tools are like using blunt instruments. Many of these payers (but not all) see oncology clinical pathways as the answer to their prayers.
Oncology clinical pathways (decision algorithms used by providers to drive treatment decision making) are gaining traction as key value-based incentive tools that are slowly replacing traditional utilization management tools. According to the 2019 Genentech Oncology Trend Report, 48% of surveyed oncologists heavily rely on pathway recommendation when choosing between multiple drugs with similar mechanism of action such as anti-PD-1 immunotherapies (wow!). According to the report, payers incentivize oncology practices to use pathways by establishing preferred provider status among those who use specific pathways and claiming that pathways streamline PA processing. In return, practices incentivize or enforce their oncologists to utilize clinical pathways through electronic or EHR notification.
Since oncology clinical pathways influence 1 in 2 providers, they have become another potential barrier for market access teams. How can manufacturers ensure favorable placement of their products in competing clinical pathways? According to the Pharmaceutical Commerce Magazine, pathways-development committees strive to remain free from bias and are very strict about the type of information manufacturers can submit for consideration. Therefore, even though manufacturers cannot directly approach pathways-development committees, these committees look to various authoritative/peer-reviewed resources that can inform them about real-world evidence, head-to-head comparisons, and cost effectiveness. Such data can be communicated via peer-reviewed journals and meetings, AMCP dossiers, and ICER reviews–to name a few communication channels.
It’s time to make big strides and turn heads–let’s go.
