Managed Care


Clinical pathways becoming widespread

MANAGED CARE December 2013. © MediMedia USA
The Formulary Files

Clinical pathways becoming widespread

Krishna R. Patel, PharmD, RPh

Payers who intend to improve patient outcomes while decreasing inappropriate drug utilization in oncology care are positioned to implement clinical pathways now more than ever before.

Prior authorization is a commonly used management strategy that is effective to a certain degree, but there is still room for improvement. Payers and practitioners alike agree that the ideal management strategy should enable practitioners to take the wheel in selecting a patient’s pharmacotherapy, which prior authorization can inhibit.

Clinical pathways can help to reduce the need for prior authorization as a management strategy while satisfying oncologists’ needs. The figure “Pathways to prior authorization goals” shows how goals of prior authorization can be met by clinical pathways.

Pathways to prior authorization goals

The 50% of plans across the nation that have already implemented pathways or plan to do so soon see that the greatest return on investment of clinical pathways is for cancer diagnoses that are most prevalent and/or are associated with the highest drug cost.

The figure below shows the most common tumor types for which pathways have been developed by health plans.

Tumor types that are most often addressed by clinical pathways

Proportion of payers

Source: “Payers Working Collaboratively With Providers to Adopt Clinical Pathways and New Care Delivery Models,” Journal of Oncology Practice, Vol. 9, issue 2


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