As medical knowledge and options in oncology treatments continue to grow exponentially, health care professionals find it increasingly difficult to stay abreast of innovations and new research that could maximize quality of care while minimizing unnecessary costs to patients and their health plans.

A recent survey found that 95% of physicians want to learn more about new trials, treatments, or procedures that could help improve outcomes, but 70% of all doctors — and 80% of oncologists — say they are overwhelmed by the amount of information they must keep up with.

Additional research calculates that 47% of prescribed cancer treatments do not follow up-to-date scientific recommendations. “As a result, many patients are not getting the best evidence-based treatments for their specific cancers and conditions,” said Dr. Stephen Hamilton, eviCore healthcare’s associate chief medical officer for oncology. “In addition, doctors who lack visibility into the financial costs of clinically equivalent therapies may not realize the potential — and potentially significant — cost differences that are shouldered by patients and their health plans.”

Evidence-based Pathways help guide the way to optimum care

Cigna Healthcare and eviCore, an Evernorth company that manages medical benefits, have pioneered a solution: The Oncology Value-based Pathways program leverages a unique, patented methodology designed to help providers fill gaps in knowledge and ensure patients get the best possible cancer care without unnecessary spending. “We review, revise, and add to our evidence-based pathways regularly as new evidence emerges,” said Dr. Hamilton, who co-authored a new study published in the July/August 2023 issue of the Journal of Clinical Pathways.

This program’s methodology utilizes value frameworks established by the American Society of Clinical Oncology, National Comprehensive Cancer Network (NCCN), and the European Society for Medical Oncology, he said. In addition, an advisory panel comprised of board-certified medical oncologists and hematologists from Cigna, eviCore, and community-based and academic oncology practices reviews the clinical appropriateness of each Pathway program regimen. The program currently spans 51 clinical pathways and covers 50% of cancers, including common diseases such as breast, lung, and colorectal cancers and relatively rare cancers such as chronic myeloid leukemia and anal cancer.

The patient’s physician makes the final decision on the care pathway

The Pathways program evaluates patient outcomes, safety, and the relative value of the treatment regimens recommended by the NCCN, then classifies them as on-pathway or off-pathway regimens. When eviCore receives a prior authorization request for an off-pathway regimen, an eviCore board-certified medical oncologist reaches out to the requesting physician to provide an overview of the clinical data supporting the on-pathway regimen. The requesting physician makes the final decision on which NCCN regimen best meets the needs of the patient.

“The Pathway program is designed to benefit cancer patients and their providers. It helps oncologists — including community oncologists, who treat a wide variety of cancers — keep up with rapidly changing clinical recommendations,” Dr. Hamilton said.

“Our primary goal is making sure that oncology providers have the best available data, including cost of the regimen when appropriate, thereby empowering them to select the most appropriate treatment regimen for their patient,” he said. “These conversations are beneficial both to the provider and to the reviewing oncologist at eviCore. For example, the provider might learn about recent studies and how an alternative approach could be more beneficial, while the eviCore oncologist can gain a better understanding of the patient’s specific circumstances and the provider’s reasons for selecting a particular pathway regimen.”

The program is designed to improve patient outcomes, which in turn often lower the cost of care, including out-of-pocket-costs for patients, Dr. Hamilton said. “Claims data from Cigna Healthcare shows that in the first year alone, the program delivered an estimated $24 million in oncology-related drug savings by reducing oncology drug expenditures while maintaining high quality care.”