Understanding Clinical Pathways: Quality, Cost, and Collaboration

Two oncology pharmacy leaders from Evolent discuss how clinical pathways—grounded in evidence and integrated with technology—are transforming cancer care by improving quality, reducing costs, and aligning with value-based care models.

Sang Chau, PharmD, BCOP: Hi, everybody. My name is Sang Chau and I'm the associate director of medical pharmacy at Evolent. I've been with the company for 8 years, going on 9. It's been a pleasure working with Evolent and all the other specialty groups, provider groups, and all of our clients and health plan partners.

Amy VanGalder, PharmD, BCOP: Hello, everyone. My name is Amy VanGalder, and I'm an associate director at Evolent as well. I've been with the company for about 2 years, and I work with our clinical pathways, helping with the development of those pathways as well as content for our oncology scientific advisory board.

I also work closely with our Oncology Evidence Collaborative, and this is where we meet with oncology practices to have detailed discussions about data and different value-based initiatives as well.

Sang, I'll go ahead and ask you the first question. How would you define a clinical pathway and how does it differ from clinical guidelines?

Chau: Good question. A clinical pathway is a structured, what we call, multidisciplinary plan that outlines the essential steps to care for patients within a specific clinical problem. It's designed to standardize care, reduce variability, and improve outcomes by aligning treatments with best practices and evidence-based guidelines.

It's a tool that has emerged in recent years in response to policy shifts, technological advances, and the rise of value-based care. They're often used to drive cost reduction and improve quality and regulatory compliance.

The difference between clinical pathways and guidelines and protocols is that clinical pathways are an operational plan that translates guidelines into step-by-step care processes, with the purpose of standardizing care delivery. On the other hand, when you're talking about clinical guidelines, they're more broad, in a sense. They are evidence-based recommendations for managing a subset of conditions with the main purpose of decision-making.

Lastly, clinical protocols are highly specific instructions for clinical actions in a specific defined scenario. The purpose of protocols, as most clinicians know, is to ensure consistency. You're following a particular protocol and can't really go off protocol.

Those are the biggest differences between the 3 different treatment pillars.

VanGalder: Sang, I'm going to ask you a follow up question too. When I talk with physician practices, one question they ask me is, "We know guidelines are more broad, but do pathways also follow the guidelines, like the National Comprehensive Cancer Network (NCCN), for instance?"

Chau: When we develop pathways, frankly, the framework starts with the guidelines—NCCN guidelines or any other physician group guidelines, like [those from] the American Society of Clinical Oncology (ASCO). That's the bare minimum.

We get the same questions. Why do we need to follow a pathway if they mimic NCCN or any large compendium? The short answer is, NCCN has all the options, but out of those 10, which ones would you pick if you had to pick and were given options? That's what clinical pathways do, try to help guide physicians to the best practice that's currently out. I hope that answers the question.

We have a few more questions. Amy, what major events, like policy changes or technological advances, have helped accelerate the adoption of clinical pathways?

VanGalder: Policies definitely help to accelerate the adoption of clinical pathways. When I think about the Affordable Care Act coming about, it tried to promote value over volume in care delivery. The Centers for Medicare & Medicaid Services (CMS) has also implemented innovative models, like the Oncology Care Model (OCM) and, more recently, the Enhancing Oncology Model (EOM). These have encouraged the use of clinical pathways as a way to standardize care and reduce the variability and cost.

Payers, as we know, have also encouraged the use of clinical pathways to help support high-value treatment options, but none of this would be possible without technological advancement. I can actually remember, back in the beginning of my career in oncology, when we were still working off from paper charts.

Pushing to electronic health records (EHRs) was key to allowing for the adoption of several value-based care initiatives, including pathway implementation. We've also seen pathway management platforms and clinical decision support tools integrated within the EHRs. This can help to drive adherence to pathway. Technology is definitely essential in order to have these pathways adhered to.

I would also probably give a little shout-out or a little nod to genomic and precision medicine tools too, because they've allowed for biomarker selection to be incorporated into pathways. This allows for additional personalization of pathways to patients based on what their molecular characteristics are as well.

Chau: I'll just add, there's one piece that we've seen now where, to really scale clinical pathways for providers to see—I think Amy mentioned it—they’ve invested in electronic medical record (EMR) integration. With that, it reaches physicians more broadly. It gives them the ability to see what's, what we call, on pathway or off pathway.

There are predictive rules to help automate approvals. At the same time, these engines can flag deviations, meaning nonpreferred or off pathway. Technological advances have definitely helped promote the use of clinical pathways.

VanGalder: That's a really good point too, Sang, because having the pathway at the fingertips of the prescriber when he's meeting with the patient is key also to be able to make those decisions right at that point, while you're having that conversation with the patient too.

Chau: Exactly.

VanGalder: What have been some of the major drivers behind the implementation of clinical pathways? I'm thinking about cost reduction, quality improvement, and maybe some regulatory requirements.

Chau: For Evolent, the first would be quality improvement. As we know, we designed clinical pathways to improve the quality by standardizing evidence-based practices.

Pathways are built on strong clinical evidence, where we review randomized clinical trials and sometimes real-world evidence. We typically start reviewing and analyzing target cancers where there may be a gap in treatment. Beyond that, we review clinical guidelines as well as reach out to experts and get their opinions on the best treatment we currently have and how the new treatments stack up against the existing alternatives.

When we're looking at outcomes for these pathways, we're looking for improved overall survival and, at the same time, any improvement in quality of life. We want to see reduction in toxicities for these new treatments. Overall, we want treatments that have high recommendations, for example, our pathways typically contain NCCN category 1 or 2 ways, which contain the highest level of evidence.

The second piece to this, in terms of drivers, is cost containment. Cost is always a factor. It is a central driver behind why clinical pathways are adopted. At Evolent, we truly believe that if you provide higher-quality care upfront, the savings will come naturally. If you treat the patient correctly, they'll have less complications and hopefully less time in your office or in the emergency room (ER) or maybe even hospitalized. Quality is number one for us, and then cost is also a factor.

VanGalder: We've seen the cost of new drugs rise so much in the last few years. I know that at Evolent, we looked at what the average annual cost of a newly approved novel therapy in 2023 was, and it was just above $300 000. Fast-forward to 2024, just a year later, and the average price was around $440 000. So, we saw a $140 000 jump in just 1 year for novel therapies. These costs are really out of control, but I completely agree. It's the outcomes. It's the outcomes we're looking for first.

Chau: I remember when checkpoint inhibitors came to market and we saw drug costs on a monthly basis between $10 000 to $15 000. We thought that was high-cost, but now, as you stated, Amy, we've seen drug costs at the half-million-dollar mark with CAR T-cell therapy, for example. We have to be mindful of the cost, not only for patients, but for our overall health care system as well.

VanGalder: One comment I hear our physicians here say—and I completely agree—is: the most expensive drug is one that doesn't work. You alluded to this earlier too, Sang.

Chau: Exactly, because then you have to go on to multiple lines of treatment and have more complications in general.

I think we can move on to next question. How does the rise of value-based care models influence clinical pathway adoption?

VanGalder: Value-based care models are definitely a key driver for pathway adoption. We mentioned briefly earlier about OCM and now EOM, and these are a few examples of some of the value-based care models from CMS.

In contrast to other models, value-based care models emphasize improving patient outcomes in standardizing care, and it also provides accountability across the care continuum.

In order to help providers succeed under value-based care contracts, clinical pathways become a key solution. The standardization that they provide helps practices to meet key metrics and outcomes, and also to optimize their value-based care contracts. We also see some of the benchmarking done for key metrics across physician practices too.

It becomes great for a practice to be able to show that they provide high-value care, and they certainly don't want to provide lower-value care than their peers.

Chau: I'll just add that we've seen value-based care shift from the focus from volume to value—in terms of seeing a high volume of patients to less patients, but making sure that there's value in their care—while, at the same time, rewarding those providers for outcomes rather than the actual services they provided or rendered. Pathways have been a tool to operationalize this even in the value-based care model there.

VanGalder: Sang, how has the payer/provider partnership played a role in expanding the use of pathways?

Chau: At Evolent, we spend a vast amount of time going through medical literature, clinical trials, and new US Food and Drug Administration (FDA) approvals, trying to identify the best practices and get them out to the physicians—our oncologist partners. But we can't make them make the changes. We're there to educate them and provide them with updates. We try, on a peer level, to convince them of our pathways.

Our partnerships of late have focused on provider engagement, and Amy can probably go more into that. She did mention at the beginning that our Oncology Evidence Collaborative is where we not only educate providers, but also train providers and their staff, and then we have performance reporting to drive pathway adherence.

It's the deep engagement that we have with our providers that help expand the use of pathways because, with pathways, not only did they stay on pathway or not stay on pathway, but we want to see roughly 70% or 80% pathway adoption or adherence. We typically don't want to see 100% adherence. That just means they're checking a box and are not thinking outside the box because oncology is complex, and we know it's not a one-size-fits-all.

Having that relationship with providers has helped. Amy, I know you work with providers on a day-to-day basis, so if there's anything you'd like to add.

VanGalder: First of all, you're absolutely correct. Not every patient is going to fit into a pathway, and so enabling the providers that know the patients best to be able to treat patients based on their clinical characteristics is a key part of pathways.

I think there can be a lot of really great synergies between payers and providers. Like you mentioned, there needs to be this collaboration, and we push each other to get to an even higher level of excellence when it comes to pathways.

We talk with providers in order to make sure that they understand what the pathways are, but then we also take feedback back from the providers to our oncology scientific advisory board to incorporate suggestions that they have as well.

By doing that, we can stay the most up to date on this ever-changing field of oncology as well.

Chau: That's a good point, Amy. We love feedback and when provider says, "Hey, how come this is not on pathway? Or why is this on pathway?" We take that back to our advisory board.