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Guidelines and Pathways: The Algorithmic Eclipse

Guidelines and Pathways: The Algorithmic Eclipse. William T. McGivney, Ph.D. Principal, McGivney Global Advisors April 12, 2014 mcgivney.wt@gmail.com.

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Guidelines and Pathways: The Algorithmic Eclipse

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  1. Guidelines and Pathways: The Algorithmic Eclipse William T. McGivney, Ph.D. Principal, McGivney Global Advisors April 12, 2014 mcgivney.wt@gmail.com

  2. Which Changes to Focus on in Cancer Care Delivery? Decision-Making in Oncology: Changes in the players, processes, electronic tools, information products, data analytics, electronic systems (EHRs, EDAs), etc Payment Methodologies: and Financing: To move from FFS to P4P and bundled payments (e.g., episode-based payments); risk sharing ; patient cost sharing Structural Change: Shifting the site of care and adding to the delivery system edifice with ACOs, Health Exchanges, PCMHs, etc.

  3. How Did We Get Here?The Road to Guidelines and Pathways 1987: Wennberg published paper on Variations in Practice 1988 and ff.: Multiple articles on 20%-30% rate of unnecessary procedures (e.g., cholecystectomy, hysterectomy) 1991 ACC/AHA Guidelines in Cardiology 1996 First NCCN Guideline (breast cancer)

  4. Basis for Policies and Decisions: Information, DATA and EDAs The NCCN Guideline Flow Down to: Guidelines, Pathways , Compendia, Protocols, Order Sets, Disease Descriptions, Patient Content etc., Coverage Policies, Precert Programs, Step Therapy, Formularies EHRs and EDAs Information Companies (etc. Zynx, Wolters Kluwer) chemo order sets, disease descriptions including management, etc.

  5. OncologistNeeds “20 Lane Highway” Information, Guidance, Guidelines, Pathways, Educational Content as they treat multiple tumor types and integrate the rapidly advancing science with multiple and varied coverage and other policies foisted upon them (in electronic formats) Information and facilitation in area of Molecular Testing “Reliable” Decision-Making Electronic Crosswalk between provider and payer Data: Quality assessment, outcomes evaluation, and understanding of resource consumption on an episodic basis Considering potential episode-based payments ; then need pathways and data

  6. Payer Needs Pathways that limit options; a 2 (or even 1) lane highway A highway where the destination is generics or biosimilars Optimal way to manage the use and spending on the 50 most costly oncology therapeutic drugs and biologics. Decision-Making Electronic Crosswalk between payer and provider Clinical data to integrate with claims data for determination of episode-based resource consumption, practice patterns for defined patient subpopulations and associated outcomes.

  7. BioPharma Needs “50 Lane Highways” Ongoing Intelligence on pathways, coverage policies, step therapy, drug discounts, etc. Information Content for their customers Data, Data, Data: Access to reliable, scientific data collection, analytic, and reporting capabilities in the form of longitudinal observational databases and adaptive trial and study design as Phase IV data needs increase for product positioning and drug development Data-based Resource Consumption analyses to support pricing, risk-sharing ,etc.; maybe even a cost-effectiveness analysis

  8. 2008: A Win for Oncology Providers and Patients Jan.16, 2008 United Press Release: If it is in NCCN Compendium, we pay for it! June 5, 2008 (4:16pm): CMS recognizes the NCCN Compendium The NCCN Compendium becomes the best friend of oncologists, cancer patients and Biopharma The NCCN Compendium flipped cancer decision-making 180 degrees It needs to be kept that way!!

  9. Policy-Setting and Decision-Making in Oncology: The Future? McKesson: Value Pathways Powered by NCCN ASCO Outcomes Thresholds/Floors: A Payer’s Dream! Big Data: Dr. Watson, CancerLinQ, University of Pittsburgh Aetna: Evolve the Payment Method and Delivery Structure: P4P compliance and shared savings Medicare: Bundled payments with episodes defined by guidelines/pathways Interpretive Pathways from multi gene assays and genomics companies!!

  10. In Conclusion The NCCN Guidelines are the Flow Down to pathways, compendia, protocols, general information products, etc. Payers want to encourage the use of pathways through a variety of programs as pathways narrow down the drug and biologic options and attempt to guide prescribing decisions to less expensive options and to generics when available. Preauthorization, step therapy, formulary with tiering and other programs like Partial or Short fills will continue to be implemented vigorously to manage drug/biologic utilization. Oncology is entering the world of having multiple agents with the same or similar mechanisms of action to treat the same tumor type! The future of algorithmic direction may be in the hands of the high throughput genomic sequencing companies as their testing results are interpreted to direct care. Ceding of Influence in Coverage by NCCN would be a Negative; NCCN influence needs to be maintained, if not enhanced!

  11. Guidelines and Pathways: The Algorithmic Eclipse William T. McGivney, Ph.D. Principal, McGivney Global Advisors April 12, 2014 mcgivney.wt@gmail.com

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