The Oncology FAC approved these guidance documents with subsequent review under the national PBM approval process. They are not mandatory for decision making but are encouraged for use at the facility or VISN level and can be found at the PBM website.
Clinical Pathways
Prostate cancer is one of the common malignancies that afflicts veterans. It is a disease with treatments involving multiple high-cost oncology drugs and as such is an ideal therapeutic area for possible intervention. Prostate cancer provides an opportunity for the second step of this project. As there are multiple therapies available for the treatment of metastatic castrate-resistant prostate cancer (mCRPC) that have been evaluated in the clinical trial setting for similar indications among comparable patient populations and are high cost items, providers find it difficult to choose among them.
A clinical pathway (CP) is a visual care map that provides direction for treatment options .6-8 Brief annotations are provided throughout the map to help provide rationale along with a rating of the clinical evidence that supports that decision. The ultimate goal of the CP is to improve patient outcomes by providing uniformity of care. Uniformity can lead to increased efficiencies, reduced chance of medication errors, and proactive management of expected toxicities. Clinical pathway development is an extensive process.
The oncology-focused NPBM-CPPMs serve as facilitators for the development of the prostate cancer pathway. This involved the creation of a database of pertinent prostate cancer literature, including national consensus guidelines (ie, National Comprehensive Cancer Network, American Urology Association). This database is available for reference and discussion throughout the process. Key VA oncologists with expertise in prostate cancer management were identified to serve as stakeholders and critically review the literature, providing input regarding each step throughout the pathway process.
Similar to previously described documents, the CP for mCRPC (CP-mCRPC) will undergo peer review by the Oncology FAC with subsequent review under the national PBM approval process. The intent of the CPmCRPC is not to mandate decision making regarding treatment but to encourage consistent treatment and ultimately to minimize variance in practice and optimize patient outcomes. Clinical pathways are dependent on the current evidence and, therefore, are documents that require evaluation and regular updates. The CP process for prostate cancer
will serve as a model for the development of subsequent pathways for other diseases.
Prior Authorization
Many commercial insurers use prior authorization (PA) solely for drug coverage decision making. The PBM has recently adopted an expanded variation of the PA process for a few select medications at both the national and VISN level. The VA PBM PA is a thorough review process to ensure that select patients are appropriate for a particular therapy in an attempt to optimize outcomes. In the process, providing drug therapy to those veterans most likely to benefit will minimize the impact of drug cost.
Drugs selected for PA review are those that meet the following characteristics: (1) Drug has demonstrated limited clinical benefit in a select subpopulation of patients; (2) Drug has a high potential for off-label use; and (3) Drug is considered a high-cost item. The potential benefits of this process are not limited just to ensuring that the appropriate patient receives the appropriate therapy. Prior authorization at the national and VISN levels promotes consistent health care delivery throughout the VA.
